St Therese Of Woodbury LLC

Location & what’s nearby

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

Quality measures — how residents actually fare

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.

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.

74.2% 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 406 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 64.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 218 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 0.99 therapist hours per resident per day in 2026Q1 — more than 97% of the 13,892 homes that report any therapy hours at all.

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

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

Staffing

How full it usually is: this home is certified for 56 beds and averages 54.3 residents a day — about 97% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.70 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.73 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.31 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 4.14 hrs/resident/day on weekends vs 4.92 on weekdays — 16% thinner on weekends. RN hours go from 1.92 to 1.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 31% is below the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

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

Inspection deficiencies

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

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

20 citations, most serious first. The 12 most serious are shown; the remaining 8 are one tap away and print in full.

• Actual harm · Gcited before2026-05-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure safe use of a wheelchair without foot pedals and added cushions was assessed for 1 of 2 residents (R28) reviewed for falls. This resulted in actual harm when R28 fell from the wheelchair during transport, sustained a right leg fracture and required hospitalization. The facility had implemented actions to prevent recurrence prior to survey on 5/26/26, therefore the citation was issued at past noncompliance. Furthermore, the facility failed to provide supervision with meals for 1 of 1 resident (R61) reviewed for nutrition. Findings include: R28's quarterly Minimum Data Set (MDS) dated [DATE], identified that R28 was cognitively intact and had diagnoses of peripheral vascular disease, hallucinations, fractures of the second and third lumbar vertebrae, heart failure, obesity, muscle weakness, and osteoarthritis. The MDS further identified that R28 was dependent on staff for transfers and mobility and was transported in a wheelchair.…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-09-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to comprehensively assess pressure ulcers and monitor for skin breakdown to prevent and/or mitigate the risk of deterioration resulting in actual harm for 2 of 3 residents when (R1) admitted with a stage 1 pressure ulcer that developed into an unstageable pressure ulcer and R2 admitted with a stage 2 pressure ulcer that developed into an unstageable pressure ulcer resulting in ongoing pain. Findings include: Definitions of pressure ulcers: Pressure Ulcer/Injury (PU/PI) is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. The appearance will vary depending on the stage and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Stage 1 Pressure Injury: Non-blanchable erythema of intact skin. Intact skin with a localized area of…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-05-29 · tag F0919 — failed to provide a working call system — pattern
  Make sure that a working call system is available in each resident's bathroom and bathing area.
  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 that a resident's call light was accessible and within reach while the resident was in the shower for 1 of 1 resident (R47) reviewed for call light accessibility. This failure had the potential to impact all residents who use the shower. Findings include:R47's quarterly Minimum Data Set (MDS), dated [DATE], identified that R47 was cognitively intact and had diagnoses of hemiplegia and hemiparesis (severe or complete paralysis of one side of the body) following a cerebral infarction (stroke) affecting the left non-dominant side, heart failure, abnormalities of gait and mobility, and muscle weakness. The MDS further identified R47 had required maximal assistance with showering and toilet hygiene.R47's care plan, dated 9/5/25, identified that R47 had experienced an activity of daily living (ADL) self-care performance deficit. Interventions included assistance from one staff member with showering and toilet hygiene. Additionally, 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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-29 · tag F0550 — failed to protect resident dignity and rights — isolated
  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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure dignity was preserved for 1 of 1 resident (R50) reviewed for dignity.Findings include: R50's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition with a BIMS (Brief Interview of Mental Status) score of 15 out of 15. His hearing was adequate without hearing aids and speech was clear. R50 required partial/moderate assist from staff for toileting hygiene. He was occasionally incontinent of urine and always continent bowel. No toileting program was in place. Diagnoses included arthritis, non-Alzheimer's dementia, and anxiety. R50's Care Area Assessment (CAA) dated 6/30/25, identified he was at risk for incontinence due to dementia, diabetes, congestive heart failure and diuretic medication use. R50's toileting care plan dated 11/11/25, identified he may self-toilet during the day and requires minimum assist of one in the evening and overnight. The care plan had not mentioned a preference to have his adult…

  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 before2026-05-29 · 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 ensure provider orders were transcribed accurately into the electronic medical record (EMR) for 2 of 2 residents (R25,R61) and failed to ensure verbal orders were received accurately for 1 of 1 resident (R15), for residents reviewed for order accuracy.Findings include: R25 R25's admission Minimum Data Set, (MDS) dated [DATE], indicated R25 had intact cognition, required substantial to maximal assistance for toileting, and was frequently incontinent of bowel and bladder. R25's diagnoses included displaced intertrochanteric fracture (broken hip) of the left femur, muscle weakness, displaced fracture of shaft of fourth metacarpal (finger) bone of right hand, and diarrhea. R25's care plan dated 4/23/26, indicated R25 was incontinent with bowel and bladder and had an ADL (activities of daily living) deficit related to diagnoses including diarrhea. The care plan indicated R25 required substantial/maximal assistance of 1 staff with toileting tasks. R25's…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-03-20 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review the facility failed to ensure facial hair was covered when plating food for delivery and failed to ensure dishwasher temperatures were maintained at required temperatures needed for proper sanitization. Furthermore, the facility failed to ensure refrigerated items were removed after expiration from 1 of 2 unit kitchens reviewed. This had the potential to impact all residents who reside in the facility. Findings include: Facial hair An observation on 3/19/25 at 11:45 a.m., cook-A and cook-B were observed in the main kitchen plating food onto plates for delivery. Cook-A and cook-B both had facial hair and with no beard covers. Cook-A and cook-B both placed food items from the steam table and the grill onto plates before placing them under a heat lamp for other dietary staff to put on trays for delivery. When interviewed on 3/19/25 at 12:03 p.m., cook-A and cook-B verified they did not have beard guards in place. Cook-A stated they were worn only when they were told by leadership to wear them. Cook-B stated he thought the facility did…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-20 · 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 2 of 2 residents (R147, R198) reviewed for Physician Orders for Life Sustaining Treatment (POLST) had the correct code status (i.e. full code, do not resuscitate-DNR) information outlined within the medical record. This could cause R147 and R198 to receive resuscitation efforts (i.e. cardiopulmonary resuscitation-CPR) against their wishes. Findings include: R198 R198's 5-day Minimum Data Set (MDS) dated [DATE], indicated R198 was cognitively intact. R198's diagnoses included osteoarthritis of right shoulder, congestive heart failure, chronic kidney disease, and hypertension. R198's face sheet printed [DATE] at 7:50 p.m., indicated R198's advance directive listed full code. R198's admission assessment dated [DATE], indicated, Code Status ON HOSPITAL ORDERS: Full Code/CPR .Code Status ON admission POLST: DNR/DNI .Does the code status on the hospital orders MATCH the code status on the admission POLST orders?: No. The admission assessment…

  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 before2025-03-20 · 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 ensure bowel monitoring for 1 of 1 resident (R33) reviewed for constipation. Findings include: R33's modification of quarterly Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition and diagnoses of chronic diastolic (congestive) heart failure, benign prostatic hyperplasia with lower urinary tract symtoms, and encounter for palliative care. It further indicated R33 required staff assistance with most activities of daily living (ADL), mobility, had a catheter, and was always continent of bowel. During interview on 3/17/25 at 2:25 p.m. family member (FM)-B stated the facility didn't monitor R33's bowel movements very well. R33's documentation (under the tasks tab) titled bowel movements (BM), for the month of March 2025, indicated R33 did not have a BM from 3/5/25-3/7/25 and from 3/15/25-3/17/25. R33's standing orders dated 2/18/25, indicated the following steps in montioring for constipation: 1. Consider rectal check to determine…

  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 before2025-03-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure recommendations were followed to minimize risk of aspiration for 1 of 1 residents reviewed for nutrition. Findings include: R23's admission Minimum Data Set (MDS) dated [DATE], indicated R23 had mild cognitive impairment and diagnoses of Parkinson's disease (illness that effects the nervous system) and dysphagia (trouble swallowing). R23 required set up for meals and had coughing or choking during meals or when swallowing medications. R23's speech therapy (ST) assessment dated [DATE], indicated ST recommended R23 to have a soft diet with bite sized food, thin liquids with no straw use. R23's provider order dated 3/3/25, indicated R23 required a soft diet with bite sized food and thin liquids. R23's orders lacked indication R23 should not use a straw. R23's [NAME] printed on 3/17/25, lacked indication R23 should not use a straw. R23's care plan revised 3/3/25, indicated R23 was at risk for nutritional and hydration deficit related to…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-20 · tag F0803 — failed to meet residents' dietary needs — isolated
  Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of 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 observation, interview and document review the facility failed to ensure meal choices were provided as ordered for 1 of 2 (R147) residents reviewed for choices. Findings include: R147's face sheet printed 3/19/25, indicated R147 was recently admitted and required care after back surgery. R147's admission assessment dated [DATE], indicated R147 was alert and orientated and had a spinal fusion. R147's provider order dated 3/9/25, indicated R147 required a regular diet with thin liquids. R147's care plan initiated 3/10/25, indicated R147 had a nutrition/hydration risk related to spinal fusion and irritable bowel syndrome (condition that can cause bloating, constipation or diahhrea and can be managed by diet). Interventions included to follow diet as ordered. A facility document titled Always Available Menu no date, indicated seasonal fresh fruit was always available as a side. R147's meal ticket dated 3/18/25, indicated R147 had ordered a plain hamburger, ketchup and fresh fruit for lunch. R147's meal…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-20 · tag F0881 — failed to use antibiotics responsibly — isolated
  Implement a program that monitors antibiotic use.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure monitoring was in place for 1 of 1 resident (R9) reviewed who had an urinary tract infection (UTI). Finding include: R9's admission Minimum Data Set (MDS) dated [DATE], indicated R9 was cognitively intact and had diagnoses of lung failure. R9 was occasionally incontinent of bowel and bladder. R9's provider progress note dated 3/4/25, indicated R9 was having urine frequency, and a UA/UC would be checked. R9's laboratory result report dated 3/5/25, indicated R9's urinary analysis/urinary culture (UA/UC) was positive and indicated R9 had a UTI. R9's provider order dated 3/6/25, indicated R9 required 1gram (gm) ceftriaxone (antibiotic) intermuscular injection once for UTI. R9's orders lacked indication R9 was monitored during symptoms or for the effectiveness of the antibiotic. R9's laboratory result report dated 3/16/25 indicated R9's UA/UC was positive and indicated R9 had a UTI. R9's provider progress note dated 3/17/25, indicated R9 was 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-09-17 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  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 meals were served in a warm, palatable manner to promote quality of life and nutritional intake for 1 of 1 resident (R3) observed for short term stay. The facility further failed to offer an alternate meal option. This had the potential to affect all 16 of 16 residents identified to reside on the unit where the meal was served. Findings include: A provided line listing report, printed 9/12/24, identified all residents and their room numbers within the [NAME] unit, including R3 who resided on the TCU unit. R3's admission Minimum Data Set (MDS) assessment dated [DATE], identified R3's cognition was intact had a diagnosis of dysphagia (difficulty swallowing) and was independent with eating, had complaints of difficulty or pain with swallowing and coughing or choking during meals or when swallowing medications and was on a mechanically altered diet. R3's Order Summary dated 9/12/24, identified a regular diet with easy to chew texture…

  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

“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.

Fines & penalties

No federal fines in the current CMS record. 2 Medicare payment denials on record.

• Medicare payment denial — starting 2026-07-01 for 2 days
• Medicare payment denial — starting 2024-10-17 for 4 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to SAINT THERESE SENIOR COMMUNITIES — 4 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 →

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

CMS files one row per role, so the 27 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

This home reported $1.9M paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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

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