Auburn Home In Waconia
594 Cherry Drive, Waconia, MN 55387 · Non profit - Corporation · 37 certified beds · (952) 442-2546 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- 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 (F0605, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $10,513 in federal fines (most recent 2025-04-02)
- 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 (2/5)
- nursing-staff turnover (62%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 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 | 2 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 2 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 | 22.5% | 18.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 10.0% | 4.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 2.4% | 1.9% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 7.5% | 2.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 4.1% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 8.4% | 4.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 29.2% | 20.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 6.1% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 96.2% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 11.5% | 5.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 39.6% | 24.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.3% | 17.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.1% | 1.9% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 85.0% | 82.7% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 15.1% | 23.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 14.0% | 14.8% | 12.0% | worse |
* 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.
58.5% 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 54 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 66.7% 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 42 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 0.47 therapist hours per resident per day in 2026Q1 — more than 78% 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
| 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 | 58.5%CMS range 48.4–68.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.7%CMS range 7.7–16.5 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 66.7% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 52.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 73.8% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 91.5% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 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 familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.1% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.1%CMS range 4.0–13.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.99 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 37 beds and averages 34.5 residents a day — about 93% occupied, or roughly 2 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 3.78 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.89 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.47 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 3.26 hrs/resident/day on weekends vs 3.99 on weekdays — 18% thinner on weekends. RN hours go from 1.05 to 0.50 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 62% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Immediate jeopardy · J2025-04-02 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 advance directives were accurately documented to reflect the resident's current wishes which affected 1 of 16 residents (R29) reviewed for advanced directives. This deficient practice resulted in an immediate jeopardy (IJ) for R29 who would have received cardiopulmonary resuscitation (CPR), contrary to their wishes, in the absence of a pulse or respirations. The IJ began on [DATE], when R29's updated physician's order for life sustaining treatment (POLST) signed on [DATE], identified R29's wishes of do not resuscitate (DNR). The three ring household binder and staff report form identified R29's wishes of CPR. The administrator and director of nursing (DON) were notified of the IJ on [DATE], at 3:35 p.m. The IJ was removed on [DATE], at 12:33 p.m., when the facility had implemented corrective action, however non-compliance remained at the lower scope and severity level of D, isolated with no actual harm but potential 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 · D2026-06-18 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
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 physician-ordered monitoring for potential adverse effects related to antipsychotic medication use was completed when orthostatic blood pressures (BP) were not obtained as ordered for 1 of 3 residents (R7) reviewed for unnecessary psychotropic medication use.Findings included:R7's quarterly Minimum Data Set (MDS), dated [DATE], identified R7 had moderately impaired cognition, and diagnoses included chronic diastolic heart failure (a condition where the heart does not fill properly, which may affect blood flow), hypertension (high blood pressure), anxiety disorder, and depression. The MDS further identified R7 received antipsychotic, antianxiety, antidepressant, and diuretic medications.R7's physician orders, print date of 6/18/26 , identified an order for Olanzapine 5 milligrams (mg) by mouth two times daily for psychosis related to depression, with target behaviors including anxiety, apathy, and somatic symptoms (physical symptoms related to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-18 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure staff implemented infection prevention and control practices when staff failed to wear required personal protective equipment (PPE), including gowns and gloves, during high-contact resident care activities for 1 of 1 resident (R4) reviewed for enhanced barrier precautions (EBP).Findings include:R4's significant change Minimum Data Set (MDS), dated [DATE], identified R4 had intact cognition, and diagnoses included benign prostatic hyperplasia (BPH; enlarged prostate which may affect the ability to empty the bladder), chronic obstructive pulmonary disease (COPD; chronic lung disease that affects breathing), severe protein-calorie malnutrition (lack of adequate nutrition which may affect the body's ability to heal and fight infections), and weakness (decreased strength which may affect mobility and ability to complete daily activities). The MDS further identified R4 required an indwelling urinary catheter (a tube inserted 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.
- Potential for harm · E2025-11-25 · tag F0712 — patternEnsure that the resident and his/her doctor meet face-to-face at all required visits.
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 physician performed an initial comprehensive assessment within 30 days after admission for 1 of 3 residents (R3), failed to ensure physician visits every 30 days after admission for 90 days for 1 of 3 residents (R3) and failed to ensure physician visits every 60 days after the initial 90 days for 3 of 3 residents (R1, R2, R3). Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was admitted [DATE]. R1 was cognitively intact with diagnoses that included Parkinson's Disease (a movement disorder of the nervous system that often causes constipation related to slow movement of food through the gut and reduced physical activity), required a wheelchair for mobility, and substantial/ maximum assistance [helper does more than half the effort] from staff for mobility.R1's progress notes dated 7/21/25 at 3:31 a.m., indicated discharge on [DATE].R1's provider visits for 2025 included nurse practitioner (NP) visits monthly…
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 before2025-11-25 · 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 timely update the family member (FM) of a change in condition for 1 of 3 residents (R1) to allow family to be involved in decisions for the resident's end of life care.Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact with diagnoses that included Parkinson's Disease (a movement disorder of the nervous system), required a wheelchair for mobility, and substantial/ maximum assistance [helper does more than half the effort] from staff for mobility. R1's progress notes dated 7/21/25 at 12:47 a.m., indicated R1 was nauseated, vomited green fluid, was short of breath, had blood pressure of 72/32 and then 87/57, pain in the right upper quadrant rated as 7 on a scale of 0-10, and a fever of 100.3 degrees Fahrenheit. The on-call administrative staff was notified, and staff left a voice message for the nurse practitioner (NP) were notified, but the progress note lacked indication R1's family 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.
- Potential for harm · D2025-11-25 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure the comprehensive care plan was updated to include interventions to address constipation and a bowel program for 1 of 3 residents (R1), who had periods of three or four days between documented bowel movements. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact with diagnoses that included Parkinson's Disease (a movement disorder of the nervous system that often causes constipation related to slow movement of food through the gut and reduced physical activity), required a wheelchair for mobility, and substantial/ maximum assistance [helper does more than half the effort] from staff for mobility. R1's orders dated 9/24/24, indicated senna-docusate (medication used to relieve constipation, also known as MiraLAX) oral tablet 8.6 milligram (mg), give 2 tablets by mouth in the morning for constipation and give 2 tablets by mouth as needed for constipation, up to 2 times a day. Further, R1'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.
- Potential for harm · Dcited before2025-11-25 · 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 interview and document review the facility delayed the transfer to the hospital after a change of condition, 1 of 3 residents (R1) who had a change in condition. R1's change of condition was identified at approximately 12:45 a.m. and was sent to the hospital at 3:30.Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact with diagnoses that included Parkinson's Disease (a movement disorder of the nervous system that often causes constipation related to slow movement of food through the gut and reduced physical activity), required a wheelchair for mobility, and substantial/ maximum assistance [helper does more than half the effort] from staff for mobility. R1 had chronic pain rated typically at 3 on a scale of 0-10. R1's progress notes dated 7/21/25 at 12:47 a.m., indicated R1 was nauseated, vomited green fluid, was short of breath, had blood pressure of 72/32 and then 87/57, pain in the right upper quadrant rated as 7 on a scale of 0-10 (severe pain),…
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 · F2025-04-02 · tag F0585 — failed to handle grievances — widespreadHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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 grievance forms and procedures were posted in prominent locations throughout the facility for residents and resident representatives to file grievances, and anonymously if desired for 4 of 4 residents (R18, R16, R19, and R7) reviewed for grievances. Findings include: On 3/31/25 at 11:00 a.m., a resident council meeting was held with four residents which included R18, R16, R19, and R7. During the resident council meeting, all four residents indicated they were unaware of how to file a grievance. During an observation on 3/31/25 at 12:00 p.m., the surveyor could not locate grievance forms throughout the facility. During a joint interview on 4/1/25 at 12:35 p.m., the administrator and director of nursing (DON) both confirmed the grievances were kept in the social service office. During an interview on 3/31/25 at 2:38 p.m., social services director (SSD) confirmed there were grievances in her office and was unable to locate grievances that were posted in prominent locations for the residents or resident…
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 · F2025-04-02 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and document review, the facility failed to ensure food items were properly labeled and dated after packaging was opened and were disposed of after the expiration date to prevent cross contamination. In addition, the facility failed to maintain a clean and sanitary kitchen area. This deficient practice had the potential to affect all 32 residents currently residing in the facility. Findings Include: During an initial tour of the kitchen and kitchenettes on 3/31/25 at 2:10 p.m., with dietary manager (DM)-A, the following areas of concern were identified: -walk in refrigerator; one large metal pan of fruit crisp, and a tray of fruit cups were covered and not dated. DM-A indicated they should have been dated and applied dated stickers to each item. -stainless steel cupboards had smears, spots and fingerprints inside and outside the doors. The stainless-steel counter below and across the Robot Coupe on the counter multiple various size crumbs were noted. DM-A indicated they did not use the Robot Coupe at this time. -Elm/Island Pantry kitchenette fridge…
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 before2025-04-02 · 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 appropriate personal protective equipment (PPE) was worn to prevent the spread of infection for for 1 of 4 residents (R25) observed for enhanced barrier precautions (EBP), (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). In addition, the facility failed to ensure safe delivery of beverages during the dining observation. This deficient practice had the potential to affect all 32 residents who resided in the facility. Findings Include: PPE: Review of Centers for Disease Control (CDC) guidance dated 4/1/24, Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) indicated Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions (EBP) included: Dressing, Bathing/showering, Transferring, Providing…
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 · F2025-04-02 · tag F0881 — failed to use antibiotics responsibly — widespreadImplement 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 establish a process for antibiotic review in order to determine appropriate indications for use of an antibiotic for 1 of 1 resident (R15) reviewed for antibiotic use. Findings include: R15's admission Minimum Data Set (MDS) dated [DATE], identified R15 had intact cognition with diagnoses of chronic heart failure, chronic kidney disease, atrial fibrillation. The MDS further identified R15 required supervision with setup help for activities of daily living (ADL's). R15's physician's orders and oncology notes were requested and not received. R15's medication administration record (MAR) dated 3/2025, included the following medication but lacked diagnoses or ongoing need for use: -Bactrim DS 800-160 milligrams (mg). Give one tablet by mouth in the morning every Monday, Wednesday, Friday for due to high dose of steroids. Bactrim order initiated 1/15/25. During an interview on on 4/2/25 at 12:58 p.m., RN-B verified R15 had been receiving Bactrim DS 800-160…
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 19 citations
- Potential for harm · F2025-04-02 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
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 acting infection preventionist (IP) had completed specialized training in infection prevention and control. This deficient practice had the potential to affect all 32 residents residing in the facility. Findings include: During an interview on 4/1/25 at 2:22 p.m., the director of nursing (DON), stated the IP resigned on 2/1/25, and the DON and two nurse managers assumed the infection control role at that time. The DON confirmed the nurse managers and herself were not enrolled in the Centers for Disease Control (CDC) infection preventionist course or any other specialized IP training. The DON added the facility was in the process of hiring a new IP. During an interview on 4/1/25 at 2:30 p.m., RN-B verified she was new to the infection preventionist role and has had no training at this time. RN-B stated the IP role was split between herself, RN-A, and DON. During an interview on 4/1/25 at 2:42 p.m., the administrator stated she was aware the facility currently had no trained infection preventionist. A facility…
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 before2025-04-02 · 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 provide timely notification to a provider for change in condition related to falls for 1 of 1 resident (R23) reviewed for falls. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 had moderately impaired cognition with diagnoses of type two diabetes with chronic kidney disease, anemia, coronary artery disease, arthritis, anxiety, difficulty in walking. Identified R23 required supervision with setup help for bed mobility, transfers, eating and limited assistance of staff for toilet use. R23's care plan dated 9/13/24, identified R23 had a mobility and self care deficit and at risk for falling related to impaired mobility, weakness, and an intellectual disorder. Staff were to monitor/document/report any changes. R23 required supervision or assist to transfer on and off toilet. R23 required supervision with transfers. Review of progress notes from 11/12/24 to 3/31/25, revealed the following: R23's progress note dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-02 · 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 bruise of unknown origin to the State Agency (SA) for 1 of 1 resident (R23) reviewed for falls. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 had moderately impaired cognition with diagnoses of type two diabetes with chronic kidney disease, anemia, coronary artery disease, arthritis, anxiety, difficulty in walking. Identified R23 required supervision with setup help for bed mobility, transfers, eating and limited assistance of staff for toilet use. R23's care plan dated 9/13/24, identified R23 had a mobility and self care deficit related to impaired mobility, weakness, and an intellectual disorder. Staff were to monitor/document/report any changes. R23's care plan lacked documentation on skin care and monitoring. Review of R23's progress notes from 11/12/24 to 3/31/25, revealed the following: R23's nursing progress note dated 11/20/24 at 9:35 p.m., stated R23 had a large purple bruise to the right…
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 · D2025-04-02 · 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 bruise of unknown origin for 1 of 1 resident (R23) reviewed for falls. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 had moderately impaired cognition with diagnoses of type two diabetes with chronic kidney disease, anemia, coronary artery disease, arthritis, anxiety, difficulty in walking. Identified R23 required supervision with setup help for bed mobility, transfers, eating and limited assistance of staff for toilet use. R23's care plan dated 9/13/24, identified R23 had a mobility and self care deficit related to impaired mobility, weakness, and an intellectual disorder. Staff were to monitor/document/report any changes. R23's care plan lacked documentation on skin care and monitoring. Review of R23's progress notes from 11/12/24 to 3/31/25, revealed the following: R23's nursing progress note dated 11/20/24 at 9:35 p.m., stated R23 had a large purple bruise to the right hip/buttock area…
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 before2025-04-02 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to provide assistance with routine grooming care which included facial hair removal for 3 of 3 residents (R7, R12, R3) reviewed for activities of daily living (ADLs) who required assistance with grooming and personal hygiene. Findings include: R7 R7's quarterly Minimum Data Set (MDS) dated [DATE], identified R7 as being cognitively intact, and diagnoses which included heart failure, asthma, macular degeneration (vision loss), and dysphagia (difficulty swallowing). R7 required moderate assistance for personal hygiene which included washing and drying face, shaving, and combing hair. R7's care plan revised on 11/4/24, identified R7 requires moderate assistance with personal hygiene. During an observation on 3/31/25 at 4:28 p.m., R7 had .25 centimeters (cm) of hair growth on the cheeks, chin, neck, and upper lips. During an observation on 4/1/25 at 8:11 a.m., R7 was sitting at the breakfast table and continued to have 0.25 cm of hair growth…
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 before2025-04-02 · 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 interview and document review, the facility failed to comprehensively assess and monitor a bruise of unknown origin for 1 of 1 resident (R23) reviewed for falls. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 had moderately impaired cognition with diagnoses of type two diabetes with chronic kidney disease, anemia, coronary artery disease, arthritis, anxiety, difficulty in walking. Identified R23 required supervision with setup help for bed mobility, transfers, eating and limited assistance of staff for toilet use. R23's care plan dated 9/13/24, identified R23 had a mobility and self care deficit related to impaired mobility, weakness, and an intellectual disorder. Staff were to monitor/document/report any changes. R23's care plan lacked documentation on skin care and monitoring. Review of R23's progress notes from 11/12/24 to 3/31/25, revealed the following: R23's nursing progress note dated 11/20/24 at 9:35 p.m., stated R23 had a large purple bruise to the right…
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 before2025-04-02 · 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 provide a comprehensive assessment (fall scene investigation) and a review or adjustment of the current fall prevention interventions to prevent falls for 1 of 1 residents (R23) who had multiple falls within the facility reviewed for falls. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 had moderately impaired cognition with diagnoses of type two diabetes with chronic kidney disease, anemia, coronary artery disease, arthritis, anxiety, difficulty in walking. Identified R23 required supervision with setup help for bed mobility, transfers, eating and limited assistance of staff for toilet use. R23's care plan dated 9/13/24, identified R23 had a mobility and self care deficit and at risk for falling related to impaired mobility, weakness, history of falls, and an intellectual disorder. R23 required supervision or assist to transfer on and off toilet. R23 required supervision with transfers. Staff were…
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 · D2025-04-02 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
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 identify diagnoses or indications for use of medications for 1 of 6 residents (R15) reviewed for unnecessary medications. Findings include: R15's admission Minimum Data Set (MDS) dated [DATE], identified R15 had intact cognition with diagnoses of chronic heart failure, chronic kidney disease, atrial fibrillation. Identified R15 required supervision with setup help for activities of daily living (ADL's). R15's physician's orders and oncology notes were requested and not received. R15's medication administration record (MAR) dated 3/2025, included the following medication but lacked diagnoses or ongoing need for use: -Bactrim DS 800-160 milligrams (mg). Give one tablet by mouth in the morning every Monday, Wednesday, Friday for due to high dose of steroids. Bactrim order initiated 1/15/25. During an interview on on 4/2/25 at 12:58 p.m., RN-B verified R15 had been receiving Bactrim DS 800-160 mg since 1/15/25, and the medication had not been reviewed…
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 · F2024-02-29 · 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 — the official record, unedited, may be distressing
Based on interview and document review, the facility failed to submit the payroll-based journal system (PBJ) staffing data to Centers for Medicare and Medicaid Services (CMS) as required. This had the potential to affect all 30 residents residing in the facility. Finding include: The facility's PBJ report 1705D dated 1/29/24, identified the facility failed to submit data for quarter three (April 1 - June 30) and quarter four (July 1 - September 30) of fiscal year 2023. During an interview on 2/29/24 at 9:10 a.m., the administrator identified the staff person who was responsible for submitting the PBJ did not submit the data the third and fourth quarter of fiscal year 2023. The facility's Electronic Staffing Data Submission Payroll-Based Journal policy dated June of 2022, identified direct care staffing and census data would be collected quarterly, and was required to be timely and accurate. The submission must be received by the end of the 45th day after the last day in each fiscal quarter in order to be considered timely.
- Potential for harm · Fcited before2024-02-29 · 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 interview and document review, the facility failed to implement a comprehensive infection control program to include timely surveillance data to identify and prevent the potential spread of communicable disease and infections for 3 of 3 residents (R22, R23, R25) who had identified potential infections. This deficient practice had the potential to affect all 30 residents residing in the facility. Findings include: The facility ABX 2024 Stewardship excel spreadsheet dated January 2024, identified unit, room number, infection type, symptoms, diagnostic test, treatment, transmission-based precautions, and date resolved. The log identified bacterial infections that required antibiotics, however, the log failed to identify/track potential viral infections or communicable rashes. The facility ABX 2024 Stewardship excel spreadsheet dated February 2024, identified unit, room number, infection type, symptoms, diagnostic test, treatment, transmission-based precautions, and date resolved. The log identified…
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 · E2024-02-29 · 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 on interview and document review, the facility failed to offer and provide the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine/ boosters and for 3 of 5 residents (R1, R2, R25) reviewed for immunizations. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 was [AGE] years old and had diagnoses that included hypertension, dementia, and chronic obstructive pulmonary disease (COPD) (refers to a group of diseases that cause airflow blockage and breathing-related problems). R1's Minnesota Immunization Report (MIIC) generated 2/28/24, identified R1 received a pneumococcal conjugate vaccine (PCV13) on 10/26/15 and a pneumococcal polysaccharide vaccine (PPSV23) on 3/16/17. R1's medical record did not include evidence R1 or R1's representative received education regarding pneumococcal vaccine booster and there was no indication R1 was offered the pneumococcal vaccine per Centers for Disease Control and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-29 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to the facility failed to ensure a resident's morning routine preferences were honored for 1 of 1 residents (R26) who voiced concerns about morning routines. Findings include: R26's admission Minimum Data Set (MDS) dated [DATE], identified R26 was cognitively intact and R26 felt it was very important that she was able to choose what to wear and to choose her bedtime. R26's care plan dated 2/9/24, identified R26 had hypersomnia (a condition in which you feel extreme daytime sleepiness despite getting sleep that should be adequate (or more than adequate) and insomnia (trouble falling asleep, staying asleep, or getting good quality sleep). R26's preference was to wake up at 9:30 a.m. R26's Island Household care sheet updated 2/1/24, identified R26 required assist of 1 for Activities of Daily Living (ADL's). Special instructions included try not to rush R26, R26 gets anxious and let her sleep until 9 or 10, whatever she wants. 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 · D2024-02-29 · 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 of observation, interview, and document review, the facility failed to ensure the nursing assistant care plan was revised to reflect updated care planned interventions for 1 of 4 residents (R15) reviewed for falls Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE], identified R15 had severe cognitive impairment, used a wheelchair for mobility, required substantial/maximal assistance (helper does more than half the effort) with transfers, and required partial/moderate assist to ambulate 10 feet. R15 had one fall since previous review. The Elm Household care sheet (nursing assistant care plan in the book) updated 1/3/24, directed staff to offer to stand/walk R15 if restless, and to ambulate the resident with stand-by-assist using a walker and pulling the wheelchair behind. The care sheet did not reflect the updated care plan dated 1/30/24, below. R15's care plan dated 1/30/24, identified R15 had a mobility and self-care deficit and was at risk for falls related to weakness, impulsivity,…
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 before2024-02-29 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review failed to provide oral and toileting/incontinence cares for 1 of 4 residents (R25); and failed to provide timely assistance with toileting/incontinence care for 1 of 4 residents (R15) reviewed for activities of daily living (ADL) and who were dependent on staff for ADL's Findings include: R25's quarterly Minimum Data Set (MDS) dated [DATE], identified R25 had a severe cognitive impairment and disgnoses included dementia with behavioral disturbance, Alzheimer's disease, anxiety, aphasia (loss of ability to understand or express speech, caused by brain damage), dysphagia (difficulty swallowing) pain, and peripheral vascular disease. R25 was frequently incontinent of bowel and bladder and was dependent on staff for all care areas. R25's Speech Therapy Outpatient Clinic SLP Eval and Plan of Treatment dated 4/10/23, identified a recommendation of puree food with ok for mechanical soft snacks when R25 was sitting upright and alert. Continue thin liquids. At that…
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 · D2024-02-29 · 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 to ensure interventsion for preventing pressure ulcers were implemented for 1 of 2 residents (R25) reviewed who was at risk for the development of pressure ulcers. Findings include: R25's quarterly Minimum Data Set (MDS) dated [DATE], identified R25 had a severe cognitive impairment and had diagnoses that included dementia with behavioral disturbance, Alzheimer's disease, anxiety, aphasia (loss of ability to understand or express speech, caused by brain damage), dysphagia (difficulty swallowing) pain, and peripheral vascular disease. R25 was at risk for pressure ulcers. R25's care plan revised 12/27/23, identified R25 was at risk for pressure ulcers related to end stage Alzheimer's disease, incontinence, reduced mobility, non-ambulatory/wheelchair bound, and spinal kyphosis. Interventions included: - Foot cradle on bed to reduce pressure to feet/toes related to redness to tops of big toes. - Turn and reposition every 2 hours. - Keep clean…
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 before2024-02-29 · 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 ensure residents were appropriately supervised to prevent falls for 1 of 2 (R15) resident reviewed for falls. In addition, the facility failed to ensure care planned fall interventions were utilized for 1 of 2 residents (R25) reviewed for falls. Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE], identified R15 had severe cognitive impairment, and diagnoses included Alzheimer's disease and bipolar disorder. R15 used a wheelchair for mobility, required substantial/maximal assistance (helper does more than half the effort) with transfers, and required partial/moderate assist to ambulate 10 feet. R15 had one fall since previous review. The facilities undated Walking/ROM Program identified on 3/15/22, R15 was not safe to ambulate; staff try to intercept when resident was attempting to walk and redirect to chair or bed. Staff may need to assist with two staff and hand-held-ambulation to walk resident to bed/chair if…
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 · D2024-02-29 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 adequate catheter care for 1 of 1 (R26) residents reviewed for catheter cares. Findings include: R26's admission Minimum Data Set (MDS) dated [DATE], identified R26 was cognitively intact and had diagnoses that included urinary tract infection (UTI) and reflex neuropathic bladder (the name given to a number of urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem)a. R26 used a indwelling foley catheter and required substantial assistance with toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after using the toilet, commode, bedpan, or urinal. If managing an ostomy, include wiping the opening but not managing equipment). R26's care plan dated 2/9/24, identified R26 required an indwelling urinary catheter. Interventions included to keep the catheter system closed as much as possible and manipulate tubing as little as possible during care. The 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.
- Potential for harm · D2024-02-29 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services 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 observation, interview and document review, the facility failed to ensure post-dialysis access site monitoring was consistently completed to provide continuity of care and reduce the risk of complication (i.e., bleeding, clotting) for 1 of 1 residents (R6) reviewed for dialysis care. Findings include: R6's quarterly Minimum Data Set (MDS) dated [DATE], identified R6 was cognitively intact and received dialysis (process of removing excess water and waste products from the blood when kidneys can no longer perform that function adequately). In addition, R6's diagnoses included end stage kidney disease, coronary artery disease (a disease caused by plaque buildup in the wall of the arteries that supply blood to the heart), chronic heart failure (chronic condition in which the heart doesn't pump blood as well as it should), and peripheral vascular disease (abnormal narrowing of arteries). R6's care plan dated 2/19/21, identified R6 had a left arm fistula. Interventions included dialysis per schedule, monitor…
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 · C2025-04-02 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
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 that three years of survey results and the plan of correction were readily accessible to residents or visitors. This deficient practice had the potential to affect all 32 residents currently residing in the facility. Findings include: During an observation on 4/1/25 at 12:00 p.m., the survey results binder was located on a shelf in a sitting area by the front door. The binder contained the last survey results noted from 2/29/24. The binder lacked the plan of correction for the 2/29/24, survey results. The binder lacked the survey results and plan of correction from the 12/1/22, survey. During a co-interview on 4/1/25 at 12:35 p.m., the administrator and director of nursing (DON) confirmed the most recent survey results from 2/29/24, were in the binder without the plan of correction and the plan of correction should have been included in the binder. The administrator and DON verified their process was to keep the most recent survey results in the binder and not the past three years. A policy on survey…
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
$10,513 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $10,513 — penalty dated 2025-04-02
- Medicare payment denial — starting 2025-05-02 for 41 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| BATTIS, STEVEN | Individual | CORPORATE DIRECTOR | since 01/22/2013 |
| HOKENESS, DANIEL | Individual | CORPORATE DIRECTOR | since 01/23/2014 |
| SANDAU, JILL | Individual | CORPORATE DIRECTOR | since 01/28/2016 |
| MARKS, JULIE | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/09/2025 |
| MAUTHE, MATTHEW | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/29/2023 |
| SHOGER, BRUCE | Individual | CORPORATE OFFICER | since 11/15/2012 |
| ZWART, ARVIN | Individual | CORPORATE OFFICER | since 01/01/2009 |
| ILLUMINUS INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/28/2025 |
| MORAVIAN CARE MINISTRIES | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 01/31/1996 |
| ELLIOTT, ABIGAIL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/10/2019 |
| HALL, JENNIFER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/28/2025 |
CMS files one row per role, so the 18 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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.
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 245583. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-18, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.