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Walker Methodist Westwood Ridge II

61 Thompson Avenue West, West Saint Paul, MN 55118 · Non profit - Corporation · 37 certified beds · (651) 259-6702 Medicare only — no Medicaid

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0605, F0609) — most recent Apr 2026Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation$15,914 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609) — 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 $15,914 in federal fines (most recent 2024-09-12)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection 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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 3 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

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
PTOSI0.2 mi
20 Thompson Ave E Ste 103 · (651) 455-2447 · Call to confirm hours
Pharmacy
1644 Robert St S · (651) 453-9671 · Call to confirm hours
Grocery
1644 Robert St S · (651) 485-0699 · Call to confirm hours
Park
Marthaler Park, 1650 Humboldt Ave · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Short-stay residents who newly got an antipsychotic medication1.8%1.9%1.4%worse
Short-stay residents given the seasonal flu vaccine52.5%82.7%79.4%worse
Short-stay residents rehospitalized after admission35.1%23.5%22.6%worse
Short-stay residents with an outpatient ER visit19.4%14.8%12.0%worse

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.

70.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 280 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

70.8%U.S. median 51.5%
Got home and stayed home
10.5%U.S. median 10.7%
Went back to hospital
52.5%U.S. median 56.6%
Met the expected recovery
0.96U.S. median 0.31
Therapy hours / resident / day
0.45hours / resident / day
Physical therapy
0.46hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 52.5% 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 120 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 0.96 therapist hours per resident per day in 2026Q1 — more than 96% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 21% 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 SNF70.8%CMS range 65.8–74.651.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.5%CMS range 8.3–14.010.7%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 discharge52.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge50.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge34.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified81.4%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS 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 stay1.4%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization4.7%CMS range 2.5–8.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.691.02Oct 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

1.83
RN hours/ resident / day
1.24
LPN hours/ resident / day
2.24
Aide hours/ resident / day
5.32
Total nurse hours/ resident / day
1.20
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 37 beds and averages 26.0 residents a day — about 70% occupied, or roughly 11 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 5.32 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.83 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.24 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.37 hrs/resident/day on weekends vs 5.69 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 2.08 to 1.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

6
deficiencies at the latest standard inspection (2026-04-15)
13
at the previous standard inspection (2025-01-23)

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.

30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.

  • Immediate jeopardy · J2024-09-12 · tag F0678 — failed to provide CPR when needed — isolated
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    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 basic life support, including cardiopulmonary resuscitation (CPR) in accordance with resident wishes and physician orders for full code status of CPR to 1 of 3 residents (R1) reviewed. This deficient practice resulted in an immediate jeopardy (IJ) situation when R1 was found not breathing, had no pulse, CPR was not initiated timely, and R1 passed away at the facility. The IJ began on 8/29/24, at 12:30 a.m. when R1 was noted to have no respirations or pulse, and no immediate action was taken by Registered Nurse (RN)-A, including CPR, which resulted in a missed opportunity to resuscitate R1, resulting in certain death. On 9/6/24, at 5:15 p.m. the administrator and director of nursing (DON) were notified of the IJ. The IJ was removed on 9/7/24, following verification of an acceptable removal plan however, noncompliance remained at the lower scope and severity level D, which indicated no actual harm with potential for more than minimal harm 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-15 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent 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 record review, the facility failed to ensure appropriate monitoring and documentation related to psychotropic medication use to include side effect monitoring and resident-specific target behaviors for 3 of 5 residents (R3, R25 and R42) reviewed for unnecessary medications. R3's face sheet dated 4/16/26, indicated R5 was admitted to the facility on [DATE]. R3's admission Minimum Data Set (MDS) dated [DATE], indicated R3 was cognitively intact and had diagnoses of schizophrenia and anxiety. R3's Order Summary Report dated 4/16/26, included the following orders: Buspirone (antianxiety medication) HCL 5 milligrams (mg), take 2 tablets, three times a day for schizoaffective disorder. Risperidone (an antipsychotic used to treat schizophrenia) 0.5 mg, take 1 tablet twice a day po for schizophrenia. Clozapine (an antipsychotic medication) 100 mg, take 400 mg once a day for schizoaffective disorder. Venlafaxine (an antidepressant medication) HCL ER oral capsule 24-hour relief, take 75 mg capsule…

    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 · D2026-04-15 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure written discharge/transfer notices were given as soon as practicable for 1 of 1 residents (R35) reviewed for hospitalization and 1 of 2 residents (R2) reviewed for discharge. In addition, the facility failed to ensure the written notice of transfer included a statement of the resident's appeal rights and the name, address, and telephone number of the entity that receives appeal requests for 1 of 1 residents (R35) reviewed for hospitalization.Findings include:R2R2's admission Minimum Data Set (MDS) assessment, dated 3/3/26, indicated R2 had intact cognition with no hallucinations, delusions, or behaviors.R2's Census information dated 2/25/26, indicated R2 was admitted to the facility on [DATE] and discharged on 4/3/26.R2's care conference note dated 3/5/26, indicated R2 would return to his assisted living facility upon discharge and would receive home health services. The note indicated R2 received intravenous antibiotics until 4/2/26, and R2…

    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 before2026-04-15 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    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 baseline care plans were in place for 2 of 5 residents (R25, R50) reviewed for baseline care plans. Findings include: R25 R25's face sheet, printed 4/15/26, indicated R25 was originally admitted to the care center on 3/16/26 with a readmission on [DATE]. R25 progress note, dated 3/28/26 indicated R25 was scheduled to discharge home that day, however, was sent to the emergency room for continued pain after a fall and was diagnosed with a pubic bone fracture. The note indicated R25 did not hold her bed at the facility. R25's progress note, dated 3/30/26, indicated R25 readmitted to the care facility after being hospitalized for a pubis and sacral bone fracture post fall. R25's entire care plan, was initiated and dated 4/13/26. R25 had a completed care plan that was canceled on 4/6/26. During an interview on 04/14/2026 at 2:28 PM, the director of nursing (DON) stated the minimum data set (MDS) nurse stated that the process is believed to occur…

    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 · D2026-04-15 · 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

    Based on observation, interview, and record review, the facility failed to ensure adequate supervision during meals for 1 of 1 residents (R42) with a known swallowing impairment who had a physician order for supervision related to holding food in the oral cavity (pocketing), and who was left unsupervised during meals despite documented risks. Findings include:R42's face sheet indicated R42 was admitted to the care facility on 4/6/26 with a primary diagnosis of pleural effusion. R42's nutrition screen, dated 4/8/26, indicated R42 was on a regular diet with regular textured foods and thin liquids. The screening further indicated that R42 could not use a straw because of a past stroke and would self-select soft foods.R42's progress note, dated 4/8/26 indicated R42 was noted to have food resident in her mouth at 7:22 p.m., and R42 required help eating due to spilling food on the floor. R42's diet order, dated 4/13/26, indicated R24 was to receive a minced and moist texture diet and required supervision while eating. R42's orders also directed staff to perform oral care after oral intake…

    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 · D2026-04-15 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure 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

    Based on interview and record review, the facility failed to ensure implementation of medication side effect monitoring for 1 of 1 resident (R42) reviewed for anticoagulant use with a known risk of bleeding. Findings include: R42's face sheet, printed 4/15/26, indicated R42 was admitted to the care facility on 4/6/26. R42's Diagnoses, dated 1/31/25, indicated R42 had a diagnosis of unspecified atrial fibrillation. R42's Orders, indicated an order, dated 4/6/26, for Eliquis (a blood thinning/anticoagulant medication) 2.5 milligram (MG) two times a day. The most common serious side effect is bleeding (i.e., gum, nose, urine, or stools). R42's electronic medical record (EMR), to include the medication and treatment administration record, active orders and care plan lacked evidence that R42's was being monitored for side effects of anticoagulation medication. During an interview on 4/14/26 at 10:03 a.m., registered nurse (RN)-B stated that medication side effect monitoring should show up on each residents' medication and treatment administration record to be documented on every shift.…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-15 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and document review, the facility failed to implement and ensure adherence to infection prevention and control practices, including appropriate use of personal protective equipment (PPE) and proper cleaning and disinfection of shared equipment for residents on contact precautions. This deficient practice placed 2 of 2 residents (R49 and R50) observed on contact precautions at increased risk for the transmission of infectious organisms. Findings include:R49's face sheet, printed 4/15/26, indicated R49 was admitted to the care facility on 4/8/26, and was on contact precautions for a history of Extended-Spectrum Beta-Lactamases (ESBL) (enzymes produced by certain bacteria that make them resistant to a variety of commonly used antibiotics).R50's face sheet, printed 4/15/26, indicated R50 was admitted to the care facility on 4/9/26, and was on contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) (a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections). During an observation…

    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 before2025-01-23 · 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 ensure proper personal protective equipment (PPE) use for 1 of 3 residents (R4) on enhanced barrier precautions (EBP) reviewed for proper PPE use during survey. In addition, the facility failed to ensure a comprehensive Infection Prevention and Control Program (IPCP) was maintained to include an ongoing analysis of collected data to help identify and reduce the risk of infection spread and outbreak. This had potential to affect all 30 residents, staff, and visitors. Findings include: R4's admission Minimum Data Set (MDS), dated [DATE], indicated R4 was dependent on facility staff for bathing, toileting and dressing and had a Foley catheter in place. During observation on 1/22/25 at 9:05 a.m., nursing assistant (NA)-E and NA-F entered R4's room. A sign was posted on R4's door indicating R4 was on enhanced barrier precautions (EBP) indicating staff must wear gown and gloves when providing high contact resident care activities including…

    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 · F2025-01-23 · tag F0881 — failed to use antibiotics responsibly — widespread
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to implement an antibiotic stewardship program which included development of protocols and a system to monitor appropriateness of antibiotic use to prevent antibiotic resistance and help prevent the spread of infectious diseases. This had the potential to affect all 30 residents residing in the facility. Findings include: During an interview on 1/22/25 at 1:46 p.m., director of nursing (DON) stated she was currently the acting facility infection preventionist and was responsible for overseeing the infection control program. DON verified the facility was currently not tracking resident antibiotic use to ensure proper use and follow up. DON verified there are currently no tracking of prophylactic antibiotics to ensure proper use and follow up. DON stated she was unaware if any antibiotic time-outs were occurring. During a follow up interview on 1/23/25 at 8:49 a.m., DON verified there are currently no antibiotic time-outs occurring at the facility. A facility policy titled Antibiotic Stewardship, revised 1/2025, indicated the…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-01-23 · tag F0882 — widespread
    Designate 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 had completed specialized training in infection prevention and control. This had the potential to affect all 30 residents residing in the facility. Findings include: On 1/22/25 at 1:26 p.m., director of nursing (DON) stated she was currently the acting facility infection preventionist and was responsible for overseeing the infection control program. DON verified that she had not completed specialized training for infection prevention and control. DON verified they were not currently enrolled in any specialized training at this time nor had any specialized infection control education scheduled. DON verified no other staff in the facility had specialized training in infection prevention and control. A facility policy titled Infection Preventionist, revised 1/2025, indicated the following: The IP will be a Registered Nurse or have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field; will be qualified by education,…

    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 · E2025-01-23 · tag F0583 — failed to protect personal privacy — pattern
    Keep residents' personal and medical records private and confidential.
    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 private and confidential resident information was secure and not visible to residents and visitors when multiple care sheets were left out in public view. This had the ability to affect eleven residents on the 400 hallway including R4. Findings include: During observation on 1/21/25 at 12:17 p.m., a medication cart down the 400 hallway was left unattended with a care sheet out in public view which identified five patient rooms which included the residents full name, diagnoses, special programs such as hospice, how alert and oriented they were, transfer and ambulation status, bowel and bladder continence, diet, precautions, skin conditions, and notes such as oxygen use, and devices used, new orders, etc. Multiple residents were seen wandering by the unattended medication cart with resident private information in sight. During an interview on 1/21/25 at 12:27 p.m., registered nurse (RN)-D stated he was working from the medication cart that day and due to the private resident information on 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · Ecited before2025-01-23 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure 5 of the 6 residents (R5, R9, R26, R28, and R133) reviewed for immunizations were offered and/or provided the pneumococcal vaccination series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). In addition, the facility failed to ensure 1 of the 5 residents (R26) was offered and/or provided the influenza vaccination as recommended by the CDC. Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated October 2024, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult who had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer, after 5 years, the Pneumococcal 20-valent Conjugate Vaccine (PCV20) or Pneumococcal 21-valent Conjugate Vaccine (PCV21) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any…

    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 · D2025-01-23 · tag F0561 — failed to honor residents' choices — isolated
    Honor 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 ensure resident choices for bathing preferences were assessed and honored for 1 of 1 residents (R5) reviewed for choices. Findings include: R5's admission Minimum Data Set (MDS), dated [DATE], indicated R5 had intact cognition with no hallucinations or delusions. On 1/21/25 at 8:57 a.m., R5 indicated he has only been out of bed one time since admission to the facility. R5 indicated he was transferred out of bed with assist of 2 staff and walker and back to bed with a Hoyer lift (mechanical lift/device that lifts patients from one place to another who cannot bear weight on their lower extremities). R5 indicated he was currently receiving hospice services. R5 indicated staff come in and wash me up and rotate me but has not had a shower since admission which he prefers. R5's care plan, printed 1/23/25, identified the following: -BATHING/SHOWERING: The resident requires assistance from 1 staff with bathing. -TRANSFER: The resident is totally dependent 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-23 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN; CMS-10055) and/or Notice of Medicare Non-Coverage (NOMNOC; CMS-10123) upon the termination of Medicare A coverage for 3 of 4 residents (R26, R187, and R188) reviewed. Findings include: R26's Census Record, printed 1/23/25, identified on 1/15/25, R26's payor source changed. The record further indicated R26 remained in the facility. R26's Centers for Medicare and Medicaid Services (CMS)-10123 signed as received on 1/10/25, identified a last covered day (LCD) of 1/14/25, when R26's Medicare coverage would end. R26's Centers for Medicare and Medicaid Services (CMS)-R-131 signed as received on 1/21/25 which was 6 days after private pay costs started and after survey entrance. R187's Census Record, printed 1/23/25, identified on 10/15/24, R187's payor source changed. The record further indicated R187's billing stopped on 10/16/24. R187's Centers for Medicare and Medicaid Services (CMS)-10123 signed as received on 10/11/25, identified a last covered day (LCD)…

    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 before2025-01-23 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    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 a copy of the resident's base line care plan for 1 of 2 resident (R26) reviewed for baseline care plans. Findings include: R26's admission Minimal Data Set (MDS), dated [DATE], indicated R26 was admitted to the care facility on 12/10/24 and was cognitively intact. R4's Care Conference Summary, dated 12/22/24, contained a section for comment that stated, copies of care plan given/sent. In the text box was typed N/A [not applicable]. During an interview on 1/22/25 at 1:51 p.m., R26 stated she had attended a care conference since she arrived at the care facility but had not received a copy of her care plan, stating I would like to see it and have a copy if possible. During an interview on 1/22/25 at 12;10 p.m., social services (SW)-A stated there process was to start the baseline care plan the day a resident was admitted but they did not provide a copy of the care plan to residents or their representatives until they discharged . During an…

    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 · D2025-01-23 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a comprehensive care plan was developed, and maintained to ensure appropriate care was provided for 1 of 5 residents (R29) reviewed for comprehensive care plan. Findings include: R5's admission Minimum Data Set (MDS), dated [DATE], indicated R5 was admitted on [DATE], had intact cognition and required maximum assistance for oral hygiene, toileting, dressing lower part of body, footwear, personal hygiene, bed mobility, and transfers. R5 required touching assistance for upper body dressing. Noted for tub/shower transfer, not applicable. R5's MDS indicated no behaviors were present, and no rejection of care exhibited. Section H: Bladder and Bowel indicating R5's always continent of bowel. Section V: Care Area Assessment (CAA) summary, the following care areas were triggered and marked as addressed in care plan: communication; ADL function/rehabilitation potential; urinary incontinence and indwelling catheter; falls; nutritional status; dental…

    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 · D2025-01-23 · 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 interview and record review, the facility failed to ensure care conferences were conducted upon admission for 1 of 2 residents (R5) reviewed for care conferences. Findings include: R5's admission Minimum Data Set (MDS), dated [DATE], indicated R5 had intact cognition with no hallucinations or delusions with an admission date of 12/31/24. Diagnoses included: heart failure, hypertension (high blood pressure), diabetes (condition that affects your blood sugar levels), depression, obstructive sleep apnea (sleep disorder characterized by episodes of a complete or partial collapse of the airway with an associated decrease in oxygen saturation or arousal from sleep), ischemic cardiomyopathy (a condition of weakened heart muscles due to heart attack or coronary heart disease), and chronic kidney disease (a condition in which the kidneys are damages and can't filter blood as well as they should). R5's progress notes, dated 12/31/24 to 1/23/25, were reviewed. Progress notes lacked evidence of R5 having a 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-23 · 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 document review, the facility failed to ensure effective collaboration between the facility and a contracted hospice organization that affected 1 of 1 residents (R5) reviewed for hospice services. Findings include: R5's admission Minimum Data Set (MDS) dated [DATE], indicated R5 was cognitively intact with no hallucinations or delusions and required maximum assistance for oral hygiene, toileting, dressing lower part of body, footwear, personal hygiene, bed mobility, and transfers. R5's diagnosis report, printed 1/23/25, included the following diagnoses: acute kidney failure (a condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few day), retention of urine (condition where the bladder doesn't empty completely), anemia (body does not have enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), Atrial fibrillation (an irregular and often rapid heart rhythm that can lead to stroke and heart…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-23 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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 comprehensively reassess and demonstrate adequate justification for the continued use of an indwelling catheter for 1 of 2 residents (R4) reviewed who used a catheter. Further, the facility failed to develop a comprehensive plan of care to monitor and assess residents with indwelling catheters for 1 of 2 residents (R4) reviewed who used a catheter. The facility further failed to ensure a resident who was continent of bowel received services to maintain bowel continence for 1 of 2 residents (R5) reviewed for bowel and bladder. Findings include: R4's admission Minimum Data Set (MDS), dated [DATE], indicated R4 was admitted to the care facility on 12/4/24, had severe cognitive impairment and was dependent on staff for bathing, toileting, and dressing. The MDS further indicated R4 had a Foley catheter on place. R4's Urology Consult Note, dated 12/27/24, indicated R4 had an indwelling Foley catheter placed by urology that day as R4 relied 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-23 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and document review, the facility failed to ensure a resident that was prescribed psychotropic medications was monitored for side effects, for 1 of 2 residents (R283) reviewed for unnecessary medications. Findings include: R283's admission Minimum Assessment Data (MDS) dated [DATE], indicated R283 had moderate cognitive impairment and no mood or behavior concerns. R283's MDS indicated diagnoses of pneumonia, heart failure, and malnutrition. R283's clinical diagnosis report indicated the following diagnoses: acute respiratory failure, severe protein calorie malnutrition, dysphagia (difficulty swallowing), chronic obstructive pulmonary disease (lung disease that blocks the airflow and makes it difficult to breathe), abscess of lung with pneumonia and acute systolic congestive heart failure. R283's clinical orders report included the following orders: 1/6/25- trazadone (antidepressant also used to treat insomnia) HCL oral tablet 50 milligrams (mg), give 0.25 tablet orally at bedtime 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-11 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to ensure 1 of 1 (R1) resident had parameters of an as needed (PRN) antipsychotic medication (medication used for a variety of mental health disorders) used for sleep. Findings include: Review of the report filed to the State Agency (SA) on 12/07/24 at 3:23 a.m., identified R1 had an unwitnessed fall and was found on the floor of her room next to her bed by staff on the unit. R1 had been assessed by the nurse and had no injuries related to the fall initially. R1 had complained of pain to her right lower leg, X-ray imaging was obtained and had identified R1 had a fracture and was sent to the emergency room (ER) for emergent evaluation. R1's Medical Diagnosis Sheet, identified a diagnosis of dementia with behavioral disturbance and depression. R1's 11/20/24, discharge Minimum Data Set (MDS) identified R1 had present behaviors that fluctuated with inattention (difficulty focusing) and disorganized thinking. R1 required substantial/maximum assistance with transfers and activities of daily living. R1 had verbal behaviors 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-12 · 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 timely for 1 of 1 resident (R1) who was recovering from neoplasm (growth of abnormal cells) bladder surgery, had pulled out their indwelling catheter and had specific orders to contact physician with change of condition. Findings include: R1's diagnoses list dated 9/5/24, identified: neoplasm of bladder, aftercare following surgery for neoplasm, acute post hemorrhagic anemia (excess bleeding), abnormal uterine and vaginal bleeding, heart failure, presence of coronary angioplasty implant and graft, diabetes mellitus (type II), history of venous thrombosis and embolism (blood clot), and gross hematuria (visible blood in urine). R1's orders from 8/27/24, through 8/29/24 included: -Code Status - Full Resuscitation order date 8/27/24. -Patient Instruction for urinary retention: If you are unable to urinate 6 to 8 hours after discharge, return to emergency room with your discharge instructions order date 8/27/24 -Discharge potential:…

    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 before2024-09-12 · 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 record review, the facility failed to immediately report to the state agency (SA) when a provider orders for life sustaining treatment (POLST) and cardiopulmonary resuscitation was not initiated timely, as per the resident wishes for 1 of 1 resident (R1) reviewed for neglect. Findings include: R1's diagnoses' list dated 9/5/24, identified: neoplasm (growth of abnormal cells) of bladder, aftercare following surgery for neoplasm, acute post hemorrhagic anemia (excess bleeding), abnormal uterine and vaginal bleeding, heart failure, presence of coronary angioplasty implant and graft, diabetes mellitus (type II), history of venous thrombosis and embolism (blood clot), and gross hematuria (visible blood in urine). R1's Provider Orders for Life-Sustaining Treatment (POLST) prepared and signed by healthcare agent/son on 8/27/24 (box checked: patient has capacity), and signed by provider on 8/28/24, identified: Attempt resuscitation/CPR (cardiac pulmonary resuscitation) (NOTE: selecting this…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-12 · 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 provide the necessary care and services for 1 of 3 residents who was recovering from bladder surgery, had pulled out their indwelling catheter and the provider was not contacted timely, provider orders to replace catheter or send to Emergency Department were not followed and ongoing assessment and monitoring for bladder retention, bleeding, or change of condition were not completed. Findings include: R1's diagnoses list dated 9/5/24, identified: neoplasm (growth of abnormal cells) of bladder, aftercare following surgery for neoplasm, acute post hemorrhagic anemia (excess bleeding), abnormal uterine and vaginal bleeding, heart failure, presence of coronary angioplasty implant and graft, diabetes mellitus (type II), history of venous thrombosis and embolism (blood clot), and gross hematuria (visible blood in urine). R1's orders from 8/27/24, through 8/29/24 included: -Code Status - Full Resuscitation order date 8/27/24. -Patient Instruction 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-02-28 · tag F0882 — widespread
    Designate 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 had the potential to affect all 33 residents residing in the facility. Findings include: When interviewed on 2/28/24, at 8:19 a.m., the administrator stated infection preventionist (IP) was the facility's designated infection preventionist. He verified that IP did not have the specialized training in infection prevention and control. He verified that IP had completed Relias trainings that all staff complete through facility and recently attended a Minnesota Department of Health Project Firstline Table Talk. During interview on 2/28/24, at 10:59 a.m., IP verified that she was the infection preventionist. IP verified that they have not completed specialized training for infection prevention and control. IP verified they were not currently enrolled in any specialized training at this time nor had any specialized infection control education scheduled. IP verified she had position of IP for greater than…

    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 · E2024-02-28 · tag F0755 — failed to provide safe pharmacy services — pattern
    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

    Based on observation and interview the facility failed to ensure 3 of 3 medication carts were free of expired facility stock medications. The findings had the potential to affect all 33 residents residing in the facility. Findings include: On 2/27/2024, at 9:38 a.m., medication cart #2 was observed with registered nurse (RN)-B. The cart contained the following expired stock medications: -bottle of vitamin D 25 mcg (micrograms), expiration date of 1/24. -bottle of docusate sodium (laxative) 100 mg (milligrams), expiration date of 9/23. -box of calcium carbonate (antaacid) 420 mg chewable tablets: packaged individually wrapped two packs, expiration date of 7/22. -bottle of vitamin B-12 1000 mg expiration 8/23. During the observation and interview, RN-B verified the expiration dates of medications listed above. RN-B stated they don't always check expiration dates prior to administration and verified that the medications [listed above] have been given to residents. RN-B stated they are going to identify who could have received them and update the needed parties. On 2/27/2024, at 9:58…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-28 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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 assess, monitor, and document for 2 of 2 residents (R89, R90) reviewed for appropriate self-administration of medications. Findings include: R89's Nursing admission assessment dated [DATE], identified orientation to person, place, time, and situation, primary language was Hmong and did not wish to self-administer medications. R89's record lacked a medication self-administration assessment and order. R89's Physician's Order Listing dated 2/26/24, identified orders for olopatadine HCl ophthalmic solution 0.1% (an antihistamine eye drop) 1 drop each eye twice a day as needed for allergies with a start date of 2/20/20/24 and cyclosporine ophthalmic emulsion 0.05% (an anti-inflammatory eye drop) 1 drop each eye twice a day when needed with a start date of 2/20/24. R89's February 2024 Medication Administration Record (MAR) indicated no ordered eye drops had been administered by facility staff. During observation on 2/26/24 at 5:26 p.m. 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-28 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and document review, the facility failed to ensure a fast-acting insulin Flexpen, and newly attached needle was primed and administered in accordance with manufacturer instructions to facilitate complete dosing of the medication for 1 of 2 resident (R122) observed to receive insulin. This had potential to deliver an incorrect dose of insulin and constituted a significant medication error. Findings include: R122's face sheet, dated 2/28/24, included diagnoses of type 2 diabetes and neurocognitive disorder with lewy bodies (form of dementia). R122's February 2024 Medication Administration Record identified R122 had a current physician order for Novolog (a fast-acting insulin) to be injected subcutaneously (under the skin) before meals per sliding scale which was listed as: 0-250 = zero (0) units, 251 - 600 = six (6) units. On 2/27/24, at 11:45 a.m., licensed practical nurse (LPN)-B obtained R122's blood sugar level from a finger prick using a glucometer. R122's blood sugar level was 413. LPN-B prepared insulin for R122 at a mobile cart in the hallway.…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-28 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to implement the current standards of vaccinations regarding pneumonia for 1 of 5 residents (R2) over [AGE] years old whose vaccinations histories were reviewed. Findings include: The Center for Disease Control and Prevention identified on the Pneumococcal Vaccine Timing for Adults Chart, dated 3/15/23, Adult [AGE] years of age or older who had received the PPSV23 (pneumococcal polysaccharide vaccine 23) only at any age should receive one dose of either pneumococcal 20-valent Conjugate Vaccine (PCV20) or pneumococcal 15-valent Conjugate Vaccine (PCV15). The dose of PCV20 or PCV15 should be administered at least one year after the most recent PPSV23 dose. R2's facility Immunization Record, print dated 2/28/24, indicated he was [AGE] years old. The record indicated he received PPSV23 on 3/16/2005. A copy of the MIIC (Minnesota Immunization Information Connection) report, provided with a report run date of 2/2/24, lacked evidence of other pneumococcal…

    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 · Dcited before2024-02-01 · 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 ensure allegations of misappropriation of property were reported within 24 hours to the State Agency (SA) for 1 of 5 residents (R1) reviewed for allegations of misappropriation of property. R1's discharge Minimum Data Set (MDS) dated [DATE] indicated R1 was cognitively intact and had almost constant pain that occasionally affected her sleep with an average pain rating of 6/10 (Pain scale where 0 is no pain and 10 is the worst pain imaginable) R1's Provider Orders included oxycodone (narcotic pain medication) 10 milligram (mg) tablet by mouth every 4 hours as needed (PRN) for pain level 8-10/10 and Ambien (sedative) 5 mg by mouth every 24 hours as needed for sleep. R1's Medication Administration Record (MAR) for January 2024 indicated R1 had requested oxycodone on 1/27/24 for a pain rating of 8/10, and Ambien to help her sleep. A Facility Reported Incident (FRI) submitted on 1/29/24 at 12:45 p.m. (approximately two days after the incident was reported…

    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

“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

$15,914 in federal fines across 1 penalty.

  • $15,914 — penalty dated 2024-09-12

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.

Part of a chain

This home belongs to VIVIE — 5 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 53.4-1.4 vs chain
Health inspection 2 of 53.4-1.4 vs chain
Staffing 4 of 54.2-0.2 vs chain
Quality measures 3 of 53.4-0.4 vs chain
The other 4 homes this chain runs (chain average 3.4★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleSince
FAIRBAIRN, SCOTTIndividualCONTRACTED MANAGING EMPLOYEEsince 09/01/2019
GRUNDHAUSER, RUSSELLIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 12/29/2016
SYLTIE, MICHAELIndividualW-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROLsince 09/25/2023
BILLBERG, GREGIndividualCORPORATE DIRECTORsince 01/01/2024
COAUETTE, CHADIndividualCORPORATE DIRECTORsince 01/01/2024
CRITZ, JULIEIndividualCORPORATE DIRECTORsince 01/01/2024
FINN, MICHAELIndividualCORPORATE DIRECTORsince 07/22/2014
GUGISBERG, MARNIEIndividualCORPORATE DIRECTORsince 01/01/2024
HANSON, PHILLIPIndividualCORPORATE DIRECTORsince 01/01/2017
JODSAAS, VICKIIndividualCORPORATE DIRECTORsince 01/01/2024
KRAFT, CAROLIndividualCORPORATE DIRECTORsince 01/01/2021
LEE, KATEIndividualCORPORATE DIRECTORsince 01/01/2022
MONTGOMERY, JEFFIndividualCORPORATE DIRECTORsince 01/01/2024
REDDEN, SCOTTIndividualCORPORATE DIRECTORsince 01/01/2022
SEMMER, FREDIndividualCORPORATE DIRECTORsince 01/01/2022
WOLF, DAVIDIndividualCORPORATE DIRECTORsince 01/01/2024
ANDERSON, MARKIndividualCORPORATE OFFICERsince 01/01/2024
PERRY, KATIEIndividualCORPORATE OFFICERsince 01/01/2024
VIVIEOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2024
WALKER METHODISTOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 09/08/2010
WALKER SENIOR SERVICES INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 09/08/2010

CMS files one row per role, so the 23 rows in the source record cover these 21 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.

3 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.

$9.0M
Net patient revenuemost recent cost report
-24.4%
Operating marginrevenue minus expenses
$513K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 25%Other / private 75%

This home reported $513K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$1,030per resident / day
operating cost
$31,298per month
≈ monthly operating cost
$827per 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

CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Minnesota Medicaid page for homes that do.

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 245618. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-15, 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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