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Parkview Care Center

55 Tenth Street Southeast, Wells, MN 56097 · Non profit - Corporation · 30 certified beds · (507) 553-3115 Medicare & Medicaid certified

Call the home — (507) 553-3115 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 Jun 2025Resident-funds citation (F0568)3 actual-harm citations1 Medicare payment denial
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a high payroll-based staffing rating (5/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0568)
  • it has 3 actual-harm citations
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its 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)

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 2 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 2 of 5

Worth a closer look. This home's staffing rating runs 3 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

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
220 S Main St · (507) 526-2211 · Call to confirm hours
Pharmacy
36 S Broadway · (507) 553-3161 · Call to confirm hours
Grocery
190 3rd St NE · (507) 553-3177 · 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 2 of 5
Long-stay residentspeople who live here 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 fell from 4 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased15.4%18.2%15.4%typical
Long-stay residents who lose too much weight3.2%4.1%5.4%better
Long-stay residents with a catheter left in their bladder10.5%1.9%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.4%2.6%2.0%better
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 injury2.7%4.0%3.3%better
Long-stay residents whose ability to walk worsened25.2%20.5%16.1%worse
Long-stay residents on antianxiety or hypnotic medication32.3%12.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%96.1%95.3%typical
Long-stay residents with pressure ulcers5.8%5.2%4.7%worse
Long-stay residents with worsening bladder/bowel control30.0%24.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table16.1%17.1%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.0%1.9%1.4%better

* 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.

51.1% 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 34 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

51.1%U.S. median 51.5%
Got home and stayed home
10.2%U.S. median 10.7%
Went back to hospital
0.16U.S. median 0.31
Therapy hours / resident / day
0.05hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.16 therapist hours per resident per day in 2026Q1 — more than 14% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF51.1%CMS range 38.1–62.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.2%CMS range 6.5–17.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care 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 staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in 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

1.08
RN hours/ resident / day
1.22
LPN hours/ resident / day
2.59
Aide hours/ resident / day
4.89
Total nurse hours/ resident / day
0.57
RN hoursweekends
54.8%
Total nursing turnover
16.7%
RN turnover

How full it usually is: this home is certified for 30 beds and averages 21.7 residents a day — about 72% occupied, or roughly 8 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.89 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.08 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.59 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 4.19 hrs/resident/day on weekends vs 5.17 on weekdays — 19% thinner on weekends. RN hours go from 1.29 to 0.57 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 55% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

1
deficiencies at the latest standard inspection (2026-06-04)
5
at the previous standard inspection (2025-06-25)

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

Inspection deficiencies

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

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

22 citations, most serious first. The 13 most serious are shown; the remaining 9 are one tap away and print in full.

  • Actual harm · Gcited before2026-02-05 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to comprehensively assess, monitor, timely develop and revise a care plan, and follow physician-ordered treatments for a surgical wound for 1 of 3 residents (R1) reviewed for non-pressure related skin injuries. The facility's failures resulted in actual harm, as evidenced by documented deterioration of R1's surgical wound from partial to complete dehiscence, with measurable increases in wound depth and tunneling, increased pain, and the need for ongoing treatments. Findings include: R1's face sheet dated 1/29/26, identified diagnoses of malignant neoplasm (cancer) of the anal canal. R1's hospital Discharge summary dated [DATE], identified R1 had been hospitalized from [DATE] through 1/2/26 for a planned robotic-assisted abdominoperineal resection (a major surgery removing that anus, rectum, and part of the sigmoid colon) with a permanent colostomy. R1's hospital After Visit Summary dated 1/2/26, included the following post procedure after…

    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
  • Actual harm · Gcited before2026-02-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to monitor, comprehensively assess, develop, and implement individualized interventions to prevent/mitigate the risk of pressure ulcers to /or deterioration for 2 of 3 residents (R2, R3) reviewed for pressure ulcers. This resulted in actual harm for R2 who developed an unstageable pressure ulcer on her right heel and stage 3 pressure ulcer on sacrum. Findings include: Pressure Ulcer/Injury (PU/PI) is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury occurs because of intense and/or prolonged pressure or pressure in combination with shear. Stage 1 Pressure Injury: Non-blanchable erythema of intact skin. Intact skin with a localized area of non-blanchable erythema (redness). Stage 2 Pressure Ulcer: Partial thickness skin loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink, or red, moist, and may also…

    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
  • Actual harm · Gcited before2025-04-24 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to comprehensively assess, monitor, and provide interventions to prevent pressure ulcer development, promote healing, and prevent deterioration for 1 of 3 residents (R3) who had pressure ulcers. The facility's failures resulted in harm when R3 developed a stage 2 pressure ulcer (PU) that deteriorated to a stage 3. Findings include: STAGING Staging of a PU/PI is performed to indicate the characteristics and extent of tissue injury, and should be conducted according to professional standards of practice. Determining whether damage to the skin and underlying tissue is a PI or PU depends on the staging of the damaged tissue. Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-06-04 · tag F0825 — pattern
    Provide or get specialized rehabilitative services as required for a 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 observation, interview and document review, the facility failed to provide physical therapy and occupational therapy as ordered for 5 of 5 residents (R2, R8, R13, R25, R26) reviewed for rehabilitation and restorative services. Findings include: R2's face sheet printed 6/4/26, indicated diagnoses of acute heart failure, chronic pain syndrome, and kidney disease. R2's care plan dated 2/17/26, indicated acute and chronic pain related to lower leg ulcers and chronic pain syndrome with interventions of non-medicated pain relief measures such as massage, physical therapy, and strengthening and stretching exercises. R2's physician's orders dated 5/29/26, indicated occupational and physical therapy eval and treat. R2's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, rejection of care one to three days, use of wheelchair, dependent on staff for toileting hygiene, lower body dressing, and personal hygiene. R8's face sheet printed 6/4/26, indicated diagnoses of dysphagia…

    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 · E2026-04-07 · tag F0568 — pattern
    Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility failed to maintain complete and accurate accounting records of resident personal funds for 10 of 10 residents (R17, R18, R19, R20, R21, R22, R23, R12, R9, R11) whose funds were maintained in a commingled facility trust account. Findings include:The facility provided resident trust statements for all the residents who had given the facility to manage. The trust statements only had the balance with no accounting of credits or debits from the account. Further the trust statements did not identify and/or account for interest earned if any. R17's trust statement dated 4/3/26, identified a balance of $94.73.R18's trust statement dated 4/3/26, identified a balance of $85.00.R19's trust statement dated 4/3/26, identified a balance of $1,899.11.R20's trust statement dated 4/3/26, identified a balance of $100.00.R21's trust statement dated 4/3/26, identified a balance of $349.00.R22's trust statement dated 4/3/26, identified a balance of $100.00.R23's trust statement dated 4/3/26, identified a balance of ($15.00). This indicated the balance was negative.R12's trust statement…

    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 · D2026-04-07 · 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 document review the facility failed to notify the physician of recurrent refusals of physician ordered medication for 1 of 1 residents (R21) who required lactulose for treatment and management of constipation and hepatic failure/alcoholic cirrhosis. Findings include R21's face sheet dated 4/3/26, identified diagnoses of chronic hepatic failure without coma, and alcoholic cirrhosis of liver without ascites.R21's quarterly Minimum Data Set (MDS) dated [DATE], identified R21 had no cognitive impairment. R21 rejected cares 1-3 days.R21's care plan dated 9/4/25, identified R12 had diagnoses of constipation and is at risk for constipation when refuses medication for constipation, is receiving laxatives-Lactulose and MiraLAX for management related to diagnoses of cirrhosis of liver. Will refuse other medications for bowels. Interventions included administer medications as ordered. Document if he refuses. Encourage R21 to sit on toilet to evacuate bowels if possible. Follow facility protocol for…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-07 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to revise behavioral care plan after resident-to-resident altercation for 1 of 1 resident (R11) reviewed for abuse. In addition, the facility failed to revise the care plan to reflect ongoing pattern of medication refusals for 1 of 1 resident (R21) who was prescribed a clinically significant medication used to treat a diagnosis of cirrhosis/hepatic failure. Findings include:R11's face sheet dated 4/2/26, identified diagnoses of Alzheimer's disease with late onset, anxiety disorder, mild cognitive impairment, and blindness of right eye.R11's physician order dated 6/12/24, identified to monitor and note behavior in progress note of irritability, verbal aggression, stating he feels down or blue, not visiting with others, walking the halls, and not eating.R11's physician order dated 6/8/25, identified to check R11's room daily for weapons such as scissors, knives, forks, etc. after recent episodes of aggression.R11's quarterly Minimum Data Set…

    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 · D2026-04-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed ensure comprehensive assessments for appropriate sling sizes for full body mechanical lift according to manufacturer guidelines to ensure safe transfers to mitigate the risk of injury for 2 of 2 residents (R16, R10) reviewed for safety.Findings include:R16R16's face sheet dated 4/2/26, identified diagnoses of encounter for closed fracture with routine healing, and muscle weakness.R16's admission MDS dated [DATE], identified R16 had severe cognitive impairment. R16 was dependent on staff for dressing, rolling, and transfers. R16 did not move from sitting to lying, lying to sitting, or sitting to standing.R16's Baseline Care Plan dated 2/5/26, identified R16 required staff assistance to transfer but did not identify how the transfer would be accomplished.R16's care plan dated 3/3/26, identified R16 required a mechanical lift with assist of two people for transfers. R16's care plan did not identify sling size to use prior to start of 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-05 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to revise the care plan for 2 of 3 residents (R1, R2) who were reviewed for non-pressure skin concerns and pressure ulcers. Findings includeR1's face sheet dated 1/29/26, identified diagnoses of malignant neoplasm (cancer) of the anal canal. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 was cognitively intact, had no behaviors of rejection of care, was independent with bed mobility, needed set up or clean up assistance for transfers, had a recent surgery that required active skilled nursing facility care that involved the gastrointestinal tract, had a surgical wound that did not have any surgical wound care. R1's activity of daily living (ADL) focus care plan dated 1/11/26, identified R1 had a self-care performance deficit related to gastrointestinal surgery. Goal to improve current level of functioning in ADLs. Interventions for transfers dated 1/11/26 as follows: R2 able to transfer with one staff and front wheeled…

    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 before2026-02-05 · 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 observations, interviews, and document review the facility failed to ensure proper handwashing/hand hygiene was implemented for 1 of 3 residents (R4) observed for handwashing/hand hygiene during wound care. Findings include:R4's face sheet dated 2/4/26, identified diagnoses of chronic venous hypertension with ulcer, congestive heart failure, diabetes mellitus with foot ulcer, and atrial fibrillation. R4's Baseline Care Plan dated 1/30/26, identified R2 had venous stasis ulcer to bilateral lower extremities. R4's hospital after visit summary dated 1/28/26, identified R4 had orders for wound care to bilateral lower extremities to cleanse with normal saline or wound cleanser, apply nonadherent dressing to any open areas, cover with ABD pads, and secure with Kerlix. R4's physician orders dated 1/29/26, identified an order to bilateral lower extremities to cleanse with normal saline or wound cleanser, apply nonadherent dressing to open areas then cover with ABD pads and secure with kerlix. During an observation and interview dated 1/30/26 at 10:23 a.m., assistant director of…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-06-25 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and document review, the facility failed to ensure plates, trays, and plate covers were completely dry before storing, and failed to ensure refrigerated food was disposed of timely to prevent bacterial growth and foodborne illness. This had the potential to affect all 18 residents residing in the facility. Findings include: During initial kitchen observation on 6/23/25 at 6:25 p.m., dietary aide (DA)-A was washing dishes. Clean plates, serving trays, and plate covers were lined up air drying near the dishwasher. During observation and interview on 6/23/25 at 7:00 p.m., DA-A had put all dishes away. DA-A was asked to lift two plates, two serving trays, and two plate covers from where they were placed stacked on top of each other on shelves without space between them to allow drainage or air drying. All plates, serving trays, and plate covers observed had visible water droplets on them. DA-A stated she always put dishes away prior to leaving her shift and thought they were dry when she put them away. During further initial kitchen 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-25 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to report the potential theft of money to the State Agency (SA) for 1 of 1 resident (R6) reviewed for personal property. Findings include: R6's face sheet received on 6/25/25, included diagnoses of anxiety and depression. R6's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. No indication of psychosis and no behaviors. R6 was dependent upon staff for most activities of daily living. R6's care plan dated 9/28/23, indicated R6 was at risk for potential abuse, neglect, or exploitation from others. R6 would remain free of documented reports of abuse. Staff would report any physical signs, comments by resident, family members of suspected abuse, neglect or exploitation of resident immediately to their supervisor or other entity as needed. During an interview on 6/23/25 at 7:28 p.m., R6 stated she lost $100 in cash about a month ago. R6 stated, I made the mistake of…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-25 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to investigate the potential theft of money for 1 of 1 resident (R6) reviewed for personal property. Findings include: R6's face sheet received on 6/25/25, included diagnoses of anxiety and depression. R6's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. No indication of psychosis and no behaviors. R6 was dependent upon staff for most activities of daily living. R6's care plan dated 9/28/23, indicated R6 was at risk for potential abuse, neglect, or exploitation from others. R6 would remain free of documented reports of abuse. Staff would report any physical signs, comments by resident, family members of suspected abuse, neglect or exploitation of resident immediately to their supervisor or other entity as needed. During an interview on 6/23/25 at 7:28 p.m., R6 stated she lost $100 in cash about a month ago. R6 stated, I made the mistake of trusting people. R6 stated…

    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
Show the remaining 9 citations
  • Potential for harm · D2025-06-25 · 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 interview and document review, the facility failed to accurately code antipsychotic medication use on Section N of the Minimum Data Set (MDS) for 1 of 5 residents (R16) reviewed for unnecessary medications. Findings include: R16's quarterly Minimum data set (MDS) assessment dated [DATE], indicated no cognitive impairment, diagnoses included schizophrenia diagnosis of diabetes mellitus, and indicated R16 did not receive antipsychotic medications since admission/entry. R16's care plan dated 4/29/25, indicated R16 received an antipsychotic medication olanzapine (antipsychotic medication used to manage symptoms of mental health conditions) for management of schizophrenia. R16's medication administration record (MAR) dated 4/1/25-4/30/25, indicated olanzapine oral tablet 20 mg (milligrams) give 1 tablet by mouth at bedtime related to schizophrenia. On 6/24/25 at 3:46 p.m., the director of nursing (DON) confirmed that she completed R16's MDS dated [DATE], and confirmed section N was inaccurately coded 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-24 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 for change in condition following computer tomography with contrast dye to ensure appropriate and prompt treatment for 1 of 1 residents (R1) who was at risk for acute renal failure. Additionally based on observation, interview, and record review the facility failed to comprehensively assess, monitor, and treat wounds for 1 of 1 residents (R2) reviewed for non-pressure skin concerns. Findings include: R1's quarterly minimum data set (MDS) dated [DATE], indicated R1 had intact cognition and was dependent on staff for all dressing, toileting, personal hygiene, transfers, and mobility with wheelchair. Further identified R1 had diagnoses that included hemiplegia following a cerebral vascular accident (CVA), heart failure, renal (kidney) failure, diabetes mellitus (inability to regulate blood sugars), dementia, and morbid obesity. The MDS also identified R1 was at risk for pressure ulcers. R1's care plan dated [DATE],…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-13 · 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 provider ordered medications were administered timely for 1 of 1 resident (R1). Findings include: R1 was admitted [DATE]. R1's admission Minimum Data Set (MDS) dated [DATE], indicated diagnosis of fracture of left ulna (a long bone in the forearm), chronic kidney disease (CKD) stage 3A, diabetes, urinary tract infection, and atherosclerotic heart disease (when plaque builds up in the walls of your arteries). Review of a fax to the provider dated 11/3/24 at 9:19 p.m., indicated R1 had completed the antibiotic. R1 indicated he was feeling better. R1 continued to have symptoms of fever, chills, and confusion. Review of a fax to the provider dated 11/4/24 at 3:26 p.m., indicated R1 had an episode of low O2 sats the evening prior and was given oxygen. R1 had a temperature of 100.7 at that time and there was no temperature since then. R1 complained of chills and feeling cold in the morning of 11/4/24. R1's lung sounds were clear but diminished 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 · Fcited before2024-08-02 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and document review the facility failed to follow the appropriate food preparation safety requirements for thawing frozen meat to reduce and/or prevent the risk of food borne illness. This had the potential to affected 25 of 25 residents who obtained their meals from the kitchen. Findings include: During observation on 7/31/24 at 11:31 a.m., oven roasted turkey breast and a pork product were individually vacuum sealed in a plastic wrap being thawed together in the middle section of a three section sink for the next day meal. While the meat was being thawed in a water bath, no continuous running cold water observed to minimize/prevent food borne illness. During interview on 7/31/24 12:04 p.m., Dietary aide-A stated staff training was completed at the facility and dietary aide-A was taught that a cold-water bath was an appropriate technique to thaw frozen meat. This technique and facility training were confirmed with the dietary manager. U.S. Food and Drug Administration ' s (FDA) Food Code 2022 Chapter 3 indicates: 3-501.13 Thawing. TIME/TEMPERATURE…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-08-02 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to perform hand hygiene during cares, clean lift equipment after use, ensure 1 of 1 staff were fit-tested with N95 masks prior to entering COVID positive resident room, and adhere to EBP (enhanced barrier precautions) for 1 of 1 residents (R2). This had the potential to impact 25 residents residing in the facility. Findings include: R2's quarterly MDS assessment dated [DATE], indicated R2 was cognitively intact, dependent on staff for transfers, dressing, hygiene, and toilet use, and had diagnoses of neurogenic bladder (loss of bladder control due to nerve damage), dementia, and heart failure. R2's care plan revised 4/8/24, indicated R2 was transferred with a mechanical lift for all transfers and was on EBP due to an indwelling urinary catheter. During an observation on 8/1/24 at 9:07 a.m., nursing assistant (NA)-B was exiting R2's room and entering R1's room. No hand hygiene was observed. At 9:11 a.m., NA-B was observed exiting R1's room…

    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 · Ecited before2024-08-02 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview and record review, the facility failed to clean resident rooms for (R80, R22, R24, R26, R18) who were on transmission-based precautions (TBP) timely and maintain an environment in good repair affecting 12 residents who used the west unit tub room. Findings include: During an interview on 7/30/24 at 8:59 a.m., housekeeper (H)-A stated housekeeping did not clean rooms of residents in TBP and stated nursing staff was supposed to clean those rooms. During an interview on 7/30/24 at 10:16 a.m., environmental services director (EVSD) stated neither housekeeping nor nursing cleaned the rooms of residents who were in TBP. EVSD stated nursing brought out the garbage and did a quick visual of the room, but did not clean toilets, floors, or high touch surfaces. If a room really needed cleaning, EVSD stated nursing would let housekeeping know and housekeeping would don PPE (personal protective equipment) and clean the room. During an observation on 7/31/24 at 7:29 a.m., R80 who was in TBP , shared an adjoining bathroom with another resident who was in TBP. 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-02 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene care (oral care and bathing) was provided for 2 of 2 residents (R26, R80) reviewed for activities of daily living (ADLs) who were dependent on staff for their care. Findings include: R80's facesheet printed on 8/1/24, included diagnoses of chronic kidney disease, fibromyalgia, and anxiety. R80 tested positive for Covid-19 on 7/29/24. R80's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R80 had moderate cognitive impairment, had clear speech, was understood, and could understand. R80 had no behaviors including rejection of care. R80 needed partial/moderate assistance for personal hygiene and was dependent upon staff for bathing. R80's care plan dated 7/24/24, indicated R80 had an ADL self-care deficient; was dependent upon staff for bathing, and required one staff assist for brushing her teeth. The care plan dated 7/15/24, indicated R80 was able to make many day-day decisions. Progress…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-02 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 implement the bowel movement (BM) protocol for 1 of 1 resident (R8) reviewed for constipation. Findings include: R8's facesheet printed on 8/1/24, included diagnoses of congestive heart failure, kidney failure, and diabetes. R8's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R8 had severe cognitive impairment, had clear speech, was understood, and could understand. R8 was dependent upon staff for toileting and was frequently incontinent of bowel and bladder. R8's physician order dated 6/7/23, included milk of magnesia oral suspension; give 30 millimeters (ml) by mouth every 24 hours as needed for constipation per standing orders. R8's standing orders (orders nursing staff can initiate independently) dated 2/16/24, included: --Day 2, if no BM, give milk of magnesia 30 ml orally every day as needed for constipation. --Day 3, if no BM, give Dulcolax suppository every day as needed for constipation. --Day 4, if no BM, administer…

    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
  • No harm found · Ccited before2025-06-25 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    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 a fan blowing directly on clean dishes was free of dust and debris. This had the potential to affect all 18 residents residing in the facility. Findings include: During initial kitchen observation on 6/23/25 at 6:25 p.m., dietary aide (DA)-A was washing dishes. Clean plates, serving trays, and plate covers were lined up air drying near the dishwasher. A small oscillating fan was turned on and blowing directly on the clean, wet dishes. The fan had visible dust and debris on the blades and surrounding cage. During observation and interview on 6/23/25 at 7:00 p.m., DA-A had put all dishes away. DA-A stated the fan was very dirty and probably should not have been blowing on the clean dishes. DA-A stated she was unaware of who was responsible for cleaning the fan or when the fan had last been cleaned. During interview on 6/24/25 at 11:50 a.m., dietary director (DD) stated was not aware the fan had gotten that dirty and thought it had just been cleaned last week. DD stated when the air conditioner ran it…

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

    Environmental Deficiencies · Deficient, Provider has date of correction

“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. 1 Medicare payment denial on record.

  • Medicare payment denial — starting 2025-05-29 for 11 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 / managerTypeRoleSince
GROSKREUTZ, WILLIAMIndividualCORPORATE DIRECTORsince 08/22/2022
NESS, JAMESIndividualCORPORATE DIRECTORsince 03/03/2014
NOORLUN, YVONNEIndividualCORPORATE DIRECTORsince 02/28/2022
WEIHE, KARENIndividualCORPORATE DIRECTORsince 12/01/2018
ANDERSON, JEANIndividualCORPORATE OFFICERsince 03/03/2014
ERICKSON, WILLIAMIndividualCORPORATE OFFICERsince 03/03/2014
HARDT, HEATHERIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/03/2021
KNOLL, CHRISTOPHERIndividualCORPORATE OFFICER; ADP OF THE SNFsince 01/01/2019
SUPPALLA, WILLIAMIndividualCORPORATE OFFICERsince 03/03/2014
JOHNSON, AARONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2021

CMS files one row per role, so the 14 rows in the source record cover these 10 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.

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.

$3.0M
Net patient revenuemost recent cost report
-14.8%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 55%Medicare 5%Other / private 39%

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

$391per resident / day
operating cost
$11,885per month
≈ monthly operating cost
$341per 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 245436. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-04, 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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