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Sainte Anne Extended Healthcare

1347 West Broadway Street, Winona, MN 55987 · Non profit - Corporation · 103 certified beds · (507) 205-6208 Medicare & Medicaid certified

Call the home — (507) 205-6208 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$22,757 in federal fines
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • 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 1 actual-harm citation
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $22,757 in federal fines (most recent 2024-11-04)

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.

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1710 Gilmore Ave · (507) 452-8990 · Call to confirm hours
Pharmacy
1213 Gilmore Ave · (507) 454-6832 · Call to confirm hours
Grocery
Aldi0.5 mi
1443 Service Dr · (855) 955-2534 · Call to confirm hours
Park
43605 Kipp Dr · (507) 643-6849 · Typically dawn to dusk
Place of worship
1303 W Broadway St · (507) 452-5656

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 2 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 improved from 2 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 increased24.3%18.2%15.4%worse
Long-stay residents who lose too much weight2.2%4.1%5.4%better
Long-stay residents with a catheter left in their bladder0.5%1.9%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.3%2.6%2.0%better
Long-stay residents with depressive symptoms7.9%4.1%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury7.1%4.0%3.3%worse
Long-stay residents whose ability to walk worsened24.8%20.5%16.1%worse
Long-stay residents on antianxiety or hypnotic medication5.6%12.5%18.9%better
Long-stay residents given the seasonal flu vaccine92.2%96.1%95.3%typical
Long-stay residents with pressure ulcers4.2%5.2%4.7%better
Long-stay residents with worsening bladder/bowel control27.2%24.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table14.1%17.1%17.1%better
Short-stay residents who newly got an antipsychotic medication1.7%1.9%1.4%worse
Short-stay residents given the seasonal flu vaccine76.4%82.7%79.4%typical
Short-stay residents rehospitalized after admission21.9%23.5%22.6%typical
Short-stay residents with an outpatient ER visit25.1%14.8%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.281.611.67better
Long-stay outpatient ER visits per 1,000 resident days2.751.901.80worse

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.

57.6% 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 42 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

57.6%U.S. median 51.5%
Got home and stayed home
10.0%U.S. median 10.7%
Went back to hospital
63.8%U.S. median 56.6%
Met the expected recovery
0.24U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 63.8% 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 47 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 0.24 therapist hours per resident per day in 2026Q1 — more than 32% of the 13,892 homes that report any therapy hours at all.

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

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF57.6%CMS range 44.9–71.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.0%CMS range 6.3–14.710.7%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 discharge63.8%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 discharge61.7%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 discharge48.9%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 identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.5%CMS range 3.2–12.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.791.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.88
RN hours/ resident / day
0.55
LPN hours/ resident / day
2.42
Aide hours/ resident / day
3.85
Total nurse hours/ resident / day
0.39
RN hoursweekends
47.7%
Total nursing turnover
40.0%
RN turnover

How full it usually is: this home is certified for 103 beds and averages 87.6 residents a day — about 85% occupied, or roughly 15 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.85 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.88 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.42 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 3.35 hrs/resident/day on weekends vs 4.05 on weekdays — 17% thinner on weekends. RN hours go from 1.08 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%.

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

Inspection trend

4
deficiencies at the latest standard inspection (2026-05-21)
6
at the previous standard inspection (2025-02-13)

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 12 most serious are shown; the remaining 10 are one tap away and print in full.

  • Actual harm · G2024-11-04 · 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 interview and document review, the facility failed to follow a care planned intervention to prevent or reduce the risk of falls for 1 of 3 residents (R1) reviewed for falls. This resulted in actual harm when R1 fell and sustained a right fibular fracture which required an emergency room (ER) visit. The facility implemented immediate corrective action, so the deficient practice was issued at past non-compliance. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had severely impaired cognition and diagnoses of dementia, fracture of upper and lower end of right fibula, anxiety disorder and depression. Further identified R1 required 2-person extensive assist with bed mobility, transfers, and toileting. R1 had one fall with injury and two falls with major injury. R1's fall Care Area Assessment (CAA) dated 5/28/24, identified R1's was at risk for falls due to R1 received physician ordered anti-depressant medications. R1 has had one fall during this assessment period. Nursing…

    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 · Past Non-Compliance
  • Actual harm · G2023-12-14 · 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 provide appropriate care in a timely manner to prevent a decline in condition for 1 of 1 residents (R32) when R32 continued to experience prolonged nausea and decline lasting more than three weeks causing harm. As a result, R32 was sent to the emergency department (ED) and admitted to the intensive care unit (ICU) after the facility failed to ensure the provider was fully appraised of R32's signs and symptoms. Findings include: R32's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R32 was admitted to the facility on [DATE] after a right knee fracture, had moderate cognitive impairment and was dependent on staff for toileting, bathing, personal hygiene, transfers, and locomotion. During an interview on 12/11/23 at 3:59 p.m., R32 stated she had not seen a physician in person since she had started feeling sick, stating she was nauseated all the time and was not able to eat much due to her nausea. R32 stated she was able…

    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 before2026-05-21 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and record review, the facility failed to ensure once opened, a bottle of tuberculin solution (solution used in intradermal skin tests to detect tuberculosis infection) was labeled in accordance to professional standard (an opened multidose vial of tuberculin PPD must be discarded 30 days after the first puncture). Additionally, the facility failed to ensure 1 of 1 resident's (R32) Lantus (insulin glargine) pen was dated once opened. Findings include: During an observation and interview on 05/18/26 at 2:09 p.m., of the fourth-floor medication refrigerator, a bottle of tuberculin solution approximately three quarters used, a light blue label on the bottle indicated, discard 30 days after opening. Close inspection of the bottle showed no open date. Licensed practical nurse (LPN)-A, present during the observation confirmed, the open bottle of tuberculin solution was not dated once opened and stated, the bottle should not have been in the refrigerator. During an interview on 05/21/26 at 8:44 a.m., registered nurse, case manager (RN)-B stated, tuberculin…

    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 · D2026-05-21 · tag F0790 — failed to provide dental care — isolated
    Provide routine and 24-hour emergency dental care for each 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 ensure routine dental services were provided or offered to promote oral hygiene and reduce the risk of complication (i.e., further breakdown, oral pain) for 1 of 1 residents (R9) reviewed for dental hygiene and services.Findings include: R9's annual Minimum Data Set, dated [DATE] identified impaired cognition and required assistance with oral hygiene. In addition, R9 with diagnoses of dementia and anxiety.R9's physician orders dated 7/22/25 state, Optometry, Audiology, Psychology, Dental, and Podiatry consults to evaluate and treat as indicated.R9's care plan dated 1/14/26 identified, need assistance with dental care d/t dementia. I have an upper partial denture.R9's electronic medical record (EMR) lacked evidence of a progress note or referral or provided a consultation for dental services.During observation and interview on 5/18/26 at 2:03 p.m., R9 was sitting in wheelchair in her room on the locked memory care unit. She had intact teeth of upper…

    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 · D2026-05-21 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each 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 ensure routine dental services were provided or offered to promote oral hygiene and reduce the risk of complication (i.e., further breakdown, oral pain) for 1 of 1 residents (R29) reviewed for dental hygiene and services. Findings include: R29's quarterly Minimum Data Set, dated [DATE] identified R29 with significantly impaired cognition, and dependent on staff for all cares including oral hygiene. In addition, R29 with diagnoses of neurocognitive disorder with Lewy body (dementia)fibromyalgia, and arthritis.R29's Dental Consult, dated 6/27/24 identified, Multiple broken teeth. Recommend extract any teeth that become symptomatic.R29's care plan with edit date of 4/9/2020 identified, Dental appointments per resident or resident representative preferences.During interview with R29's emergency contact (FM)-B on 5/20/26 at 12:15 p.m., FM-B stated he expected the facility to arrange for routine dental services and could not recall the last time R29 was…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-21 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure food stored in a unit refrigerator were labeled, dated and discarded properly. Additionally, facility failed to ensure proper food storage for 1 of 1 resident refrigerator that contained undated and unlabeled food.Findings Include:During an observation on 05/20/26 9:05 a.m., the fourth-floor kitchen refrigerator contained the following items: 3 clear sandwich size bags with egg salad sandwiches labeled with room number and undated, 1 small size of uncovered paper bowl of [NAME] tot and a taco wrapped in brown paper from taco [NAME], not labeled and undated. 3 small (2 .25 oz) plastic portion cups, black container, clear covering, holding a creamy and medium consistency substance, not labeled and undated. A medium size (16 oz) food container with a red lid, holding a mixture of ground brown meat, and a reddish liquid labeled with a room number and dated 5/14/26. During an interview on 05/20/26 9:05 a.m., nursing assistant (NA)- A,…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-02-13 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    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 a dignified dining experience for residents who required assistance with eating. This had the potential to affect all residents in the facility who were dependent on staff for their intake of nutrition. Findings include: During an observation of the main floor dining room on 2/10/25 at 5:08 p.m., nursing staff were standing while feeding residents. The staff would move from table to table to assist different residents and were found to not have engaged with the residents during the meal. During an observation on 2/11/25 at 11:55 a.m., nursing staff were standing during lunch meal and moving from resident to resident. During an observation on 2/12/25 at 12:22 p.m., the 5th floor common area was used for meals. Nursing assistant (NA-C) was assisting residents with their meals while standing. NA-C would call out, out loud asking if the residents needed any assistance. During an interview on 2/12/25 at 12:32 p.m., NA-E explained most of the residents need some sort of assistance during meals and most days…

    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 · Ecited before2025-02-13 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and document review, the facility failed to maintain separately locked, permanently affixed compartments for storage of controlled drugs for 4 of 4 observed medication storage areas during a facility wide remodel. Findings include: During an observation and interview on 2/13/25 at 9:08 a.m., licensed practical nurse (LPN)-B identified the current refrigerator used to store medication on the 2nd floor was locked. The locked refrigerator was not affixed to any permanent surface and was in a temporary nurse's station in the open while the facility was in the middle of a remodel. LPN-B identified the medications in the refrigerator contained flu shot, insulin pens, tuberculin, and Ativan (antianxiety). LPN-B stated the nurses are the ones who check the expiration dates and refill the refrigerator. During observation of the 3rd, 4th, and 5th floor medication storage areas, it was found each had the same type of refrigerator located in a temporary nurse's station as found on the 2nd floor. The nursing staff carry a key to the locked refrigerator which was…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-13 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    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 observations, interview, and document review the facility failed to ensure compression stocking were applied as ordered to help with edema of the lower extremities for 1 of 1 resident (R10) reviewed for activity of daily living . Findings include: R10's annual Minimum Data Set (MDS) assessment dated [DATE], included R10 cognitive status was intact and required minimal assistance with activities of daily living. R10's face sheet dated 11/17/23 included diagnoses of disorders of veins, localized edema, essential hypertension, history of acute embolism and thrombosis related to deep veins of bilateral lower extremities, cerebral infarction (stroke or bleeding in the brain), and generalized weakness. R10's medical record included, an order to apply compression stockings daily every a.m. and remove at HS (at night). During an observation on 2/10/25 at 1:15 p.m., R10 was resting in a recliner noted to have edema bilaterally to lower extremities. During an interview on 2/10/25 at 1:31 p.m., R10 said both…

    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 · D2025-02-13 · 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 grooming was completed who was dependent on staff for personal cares for 1 of 1 resident (R62), reviewed for activities of daily living (ADL)'s . Findings include: R62's minimum data set (MDS) assessment dated [DATE], indicated mild cognitive impairment and was dependent on facility staff to complete personal hygiene tasks. R62's face sheet included the diagnosis of peripheral autonomic neuropathy (nerve damage), thoracic spondylosis (a condition that affects the middle part of your spine, causing pain, stiffness, and nerve compression), generalized muscle weakness, and hemiplegia ( paralysis of one side of the body) R62's care plan dated 1/24/25 indicated a self-care deficit related to personal hygiene and bathing and required substantial assistance from facility staff. During observation and interview on 2/10/25 5:08 p.m., R62 had facial hair present on the right upper lip and chin. Right upper lip contained a patch 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    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 replace and maintain oxygen tubing for 2 of 2 residents (R32 and R65) reviewed for respiratory care. Findings include: R32's Minimum Data Set (MDS) assessment, indicated severe cognitive impairment and received supplemental oxygen. R32's order report dated 1/4/2025, indicated diagnoses of primary emphysema (chronic lung condition that causes shortness of breath), respiratory failure, and hypoxemia and R32 active orders instructed staff to deliver continuous oxygen and to titrate (continuously measure and adjust the balance) amount to maintain oxygen saturation above 88%. During an observation on 2/10/25 at 1:44 p.m., R32's oxygen tubing was dirty under the nasal area. This tubing was hooked up to a concentrator with a long extension and tied in a knot with R32's wheelchair sitting on top of the tubing. During an interview on 2/11/25 at 10:45 a.m., licensed practical nurse (LPN-C) explained the process for changing and maintaining oxygen tubing. The current process was a scheduled task during a nursing 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-13 · 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 record review, the facility failed to appropriately clean resident medical equipment after use and place barrier between resident high touch surface and resident multiuse basket. This had the potential to affect all resdient's who received blood glucose monitoring. In addition, the facility failed to ensure proper use of personal protective equipment (PPE) during cares for 1 of 3 residents (R36) reviewed for enhanced barrier precautions (EBP). Findings include: During medication administration on 2/10/25 at 3:47 p.m. registered nurse (RN)-C set up medications for R35. R35 also required to have a blood sugar checked. RN-C had a basket containing the following: lancets (device to puncture the skin for blood sample), test strips, sharps containers, cotton balls and on top was a glucometer (machine to get results of the blood sample). Once in R35's room RN-C placed the basket on a chair then moved the basket from the chair to the resident tray table with out placing a barrier between the tray table and the basket. After RN-C completed the glucose…

    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
Show the remaining 10 citations
  • Potential for harm · Dcited before2024-05-15 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure proper hand hygiene during personal cares and wound care for 1 of 1 resident (R3) observed for infection control practices. Finding include: R3's face sheet identified diagnoses that included chronic heart failure, dementia with behavioral disturbances, and difficulty walking, R3's quarterly minimum data set (MDS) dated [DATE], identified R3 was usually understood and sometimes understands with verbal and nonverbal expressions, had severe cognitive impairment, and was dependent on staff for assistance with most to all dressing and grooming activities. R3's infection care plan dated 5/6/24, identified R3 required enhanced barrier precautions and staff are to apply gloves and gowns prior to facility-identified high-contact care activities, discard personal protective equipment (PPE) is designated location following activities and sanitize hands after PPE removal. R3's skin care plan dated 1/11/24, identified pressure area to left…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-12-14 · 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, interview and document review, the facility failed to ensure narcotics were counted in a manner to detect potential diversion at shift change for 2 of 7 medication carts reviewed. Findings include: On 12/12/23 at 2:50 p.m., licensed practical nurse (LPN)-B on-coming staff and LPN-C off-going staff counted narcotics in two carts. LPN-B unlocked the drawer and would call out the group number and the page number. LPN-C would look for the page number in the narcotic book and LPN-B would say how many pills or milliliters (ml) if it was a bottle with liquid. LPN-C would confirm the number or ml was correct. The index page and/or paging through each page was not used to ensure all medications were accounted for. LPN-B stated the on-coming staff was in the drawer and the off-going staff was looking in the book. On 12/12/23 at 2:58 p.m., LPN-B stated unless they looked at each page in the book they would not know if a card or bottle was missing. LPN-B verified they did not review each page and not all medications had been signed into the index page of the narcotic book.…

    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 · Ecited before2023-12-14 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and document review, the facility failed to ensure medications were labeled appropriately with open dates. In addition, the facility failed to remove expired medications for 6 of 82 residents (R76, R29, R34, R16, R39) whose medications were observed during medication storage. Findings include: During the medication storage tour on the second floor on 12/13/23 at 2:11 p.m., with trained medication aide (TMA)-B there were medications with no open dates and medications/items past the expiration date as listed below: -lantus insulin for R29 with no open date -29 hydrogen peroxide wipes manufacturer's expiration date of 11/9/22 -copper tone sun screen with manufacturer's expiration date of 11/2020 -equate sport sun screen with manufacturer's expiration date of 11/2020 -mineral oil with manufacturer's expiration date of 12/5/22 On 12/13/22 at 2:15 p.m., registered nurse (RN)-A stated medication carts should be checked monthly for expired medications. RN-A stated this was important to ensure residents did not receive medications which had expired. During 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-12-14 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and document review, the facility failed to ensure communal vital signs machine was disinfected between resident use for 2 of 2 residents (R61, R71) observed to have vital signs checked conducted without proper disinfection of the machine. This practice had the potential to affect all 26 of 26 resident residing on the floor. Findings include: On 12/14/23 at 7:49 a.m., licensed practical nurse (LPN)-A was observed to enter R71's room with the communal vital sign machine. LPN-A proceeded to take vital signs for R71 and exited her room. LPN-A was not observed to disinfect the vital sign machine. There were no disinfecting wipes observed on the vital sign machine. The vital sign machine was left in the hallway, while LPN-A stopped and talked to another staff. On 12/14/23 at 7:51 a.m., LPN-A was observed entering R61's room with the communal vital sign machine that had not been disinfected. LPN-A proceeded to take vital signs for R61. Upon exiting the room, the communal vital sign machine was placed by the nursing station, by the scale without being…

    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 · E2023-12-14 · 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 implement the current standards of vaccinations regarding pneumonia for 4 of 5 residents (R13, R17, R31, and R72) over [AGE] years old whose vaccinations histories were reviewed. Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R13's facility immunization record, dated 12/12/23, indicated she was [AGE] years old. The record indicated she received a PCV13 on 6/4/2013 followed by the PPSV23 on 9/15/2015. A copy of the MIIC…

    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 · D2023-12-14 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure a resident's code status was consistent across the Electronic Medical Record (EMR) and paper chart for one of 10 residents (R46) reviewed for advanced directives. Finding include: R46's Face Sheet, indicated R46 was admitted to the facility on [DATE] with a primary diagnosis of hemiplegia and hemiparesis following a cerebral infarction affecting her left, non-dominant, side. The banner at the top of R46's face sheet further indicated R46's code status was do not resuscitate (DNR)/ do not intubate (DNI). R46 physician order, dated [DATE], indicted R46's code status was DNR/DNI. R46's Provider Order for Life-Sustaining Treatment (POLST), dated and signed by R46 on [DATE], indicated R46 would like cardiopulmonary resuscitation (CPR) if she had no pulse and/or was not breathing and would like full treatment to include intubation, advanced airway interventions and mechanical ventilation as indicated. R46's Health Care Directive, dated and signed by…

    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 · D2023-12-14 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to fully and accurately complete the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) (Form CMS-10055) for two of three residents (R13 and R64) reviewed for beneficiary notices. Findings include: The SNFABN contains a section with three options for the resident or resident representative to select. Option One indicates the resident would like the care listed above and recognizes payment responsibility but would like Medicare to be billed for an official decision on payment, Option Two indicates the resident would like the care listed above and recognizes payment responsibility but does not want Medicare billed and Option Three indicates the resident does not want the care listed above. R13's face sheet, indicated R13 was admitted to the facility on [DATE] with a primary diagnosis of senile degeneration of the brain. R13's Progress Note, dated 6/21/23, indicated R13's skilled services would be ending on 6/23/23 with financial…

    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 · D2023-12-14 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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 they were free of a medication error rate of five percent or greater. The facility had a medication error rate of 6.9 % with two errors out of 30 opportunities for error involving 2 of 6 residents (R73, R61)who were observed during the medication pass. Findings include: R73's annual Minimum Data Set (MDS) assessment dated [DATE], identified R73 was severely cognitively impaired and had diagnoses which included cancer, diabetes mellitus, dementia, and depression. R73's Physician Order Report identified R73 had orders as follows: -10/9/23, Humalog insulin 100 units per milliliter (ml) 17 units subcutaneously once a day between 11:00 a.m. and 1:00 p.m. On 12/12/23 at 12:18 p.m., during an observation licensed practical nurse (LPN)-A prepared Humalog insulin for R73 by scrubbing the hub of the pen, placing a disposable needle on the pen and priming the needle by dialing two units and wasting the insulin. LPN-A then dialed up 17 units…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-31 · 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

    Based on interview and document review the facility failed to administer hypoglycemic (low blood sugar) treatments and medications in accordance to physician standing orders for 2 out of 2 residents (R1,R2) reviewed for nursing services. Findings include R1's face sheet indicated R1 had diagnoses of rheumatoid arthritis, congestive heart failure (condition in which the heart doesn't pump blood as efficiently as it should), and morbid (severe) obesity. R1's Facility Standing House Orders for Symptom Management, revised 5/22, indicated, hypoglycemia blood glucose (BG) (BG<70) Administer 6 ounce (oz). of fruit juice, mild or high carbohydrate beverage orally or glucose tabs or gel orally or via feeding tube Repeat BG after 10 minutes, if <70 repeat above intervention If after 2 attempts to treat and BG is still <70, notify provider. If patient is unresponsive or unable to swallow and does not have feeding tube. Administer Glucagon 1 mg IM Repeat BG after 10 minutes; if <70 and patient is still unresponsive, repeat Glucagon dose After giving a second Glucagon dose, if patient is still…

    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 · D2023-10-31 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    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, observation and record review, the facility failed to maintain a complete and accurate medical record for 2 of 2 residents (R1, R2) who required hypoglycemic treatment and management. Findings include R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had diagnoses that included, Atrial fibrillation, coronary artery disease, heart failure and was medically complex. R1's Standing House Orders for Symptom Management, dated and signed by the physician on 7/2/23, included the following orders in the event of hypoglycemia for blood glucose (BG) <70 -Administer 6 ounces of fruit juice, mild or high carbohydrate beverage orally or glucose tabs or gel orally or via feeding tube Repeat BG after 10 minutes, if <70 repeat above intervention If after 2 attempts to treat and BG is still <70, notify provider. -If patient is unresponsive or unable to swallow and does not have feeding tube. Administer Glucagon (a hormone that your pancreas makes to help regulate your blood glucose levels)1…

    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

“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

$22,757 in federal fines across 2 penalties.

  • $10,839 — penalty dated 2024-11-04
  • $11,918 — penalty dated 2023-12-14

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 BENEDICTINE HEALTH SYSTEM — 23 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 4 of 52.8+1.2 vs chain
Health inspection 4 of 52.5+1.5 vs chain
Staffing 4 of 54.0≈ chain avg
Quality measures 3 of 52.9+0.1 vs chain
The other 22 homes this chain runs (chain average 2.8★, 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
BITTNER, DAVIDIndividualCORPORATE DIRECTORsince 02/01/2025
BRUHN, JENNIFERIndividualCORPORATE DIRECTORsince 11/25/2019
DEMARAIS, THOMASIndividualCORPORATE DIRECTORsince 09/01/2025
ERWIN, JAMESIndividualCORPORATE DIRECTORsince 10/01/2017
KILKUS, PAULIndividualCORPORATE DIRECTORsince 09/01/2018
MAREK, PATRICKIndividualCORPORATE DIRECTORsince 01/24/2018
STELMAN, JOANIndividualCORPORATE DIRECTORsince 10/01/2019
THOMPSON, WILLIAMIndividualCORPORATE DIRECTORsince 09/01/2025
BERGIEN, TRICIAIndividualCORPORATE OFFICERsince 07/17/2017
RYMANOWSKI, KEVINIndividualCORPORATE OFFICERsince 01/01/2008
BENEDICTINE HEALTH SYSTEMOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/1997
BAER, MEGANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/06/2024
EHLINGER, CAROLIndividualOPERATIONAL/MANAGERIAL CONTROLsince 08/02/2019
FORSYTH, JENNIFERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2025

CMS files one row per role, so the 17 rows in the source record cover these 14 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.

1 organizational owner 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.

$11.4M
Net patient revenuemost recent cost report
-8.3%
Operating marginrevenue minus expenses
$1.0M
Related-party expense8% of expenses
Who pays — share of resident-days
Medicaid 43%Medicare 3%Other / private 53%

This home reported $1.0M 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 2024. 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

$408per resident / day
operating cost
$12,390per month
≈ monthly operating cost
$376per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). 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 245233. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-21, 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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