Zumbrota Care Center
433 Mill Street, Zumbrota, MN 55992 · Non profit - Corporation · 42 certified beds · (507) 732-8400 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (5/5)
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $28,321 in federal fines (most recent 2025-05-27)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 19.2% | 18.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 0.0% | 4.1% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 9.7% | 1.9% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 2.6% | 2.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 2.8% | 4.1% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 11.8% | 4.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 15.9% | 20.5% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 3.7% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.4% | 5.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 22.2% | 24.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 4.5% | 17.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.7% | 1.9% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 82.7% | 79.4% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
47.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 36 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 65.6% 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 32 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 0.20 therapist hours per resident per day in 2026Q1 — more than 22% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 47.1%CMS range 33.3–63.4 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.8%CMS range 6.5–15.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 65.6% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 56.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 56.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.95 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 42 beds and averages 33.8 residents a day — about 80% occupied, or roughly 8 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.66 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.48 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.85 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 3.13 hrs/resident/day on weekends vs 3.88 on weekdays — 19% thinner on weekends. RN hours go from 1.68 to 0.99 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. 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.
24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.
- Immediate jeopardy · Jcited before2025-05-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to maintain a functioning Wanderguard system and failed to comprehensively assess risk for elopement and appropriate interventions, resulting in elopement for 2 of 7 residents (R1, R2). R1's elopement occurred due to the failure of the Wanderguard system, which did not sound an alarm when R1 exited the building. R2's elopements occurred due to R2's risk of elopement was not accurately comprehensively assessed leading to insufficient supervision and lack of intervention, followed by a failure of the Wanderguard system. The facility's failures resulted in an immediate jeopardy (IJ). The immediate jeopardy began on 5/8/25, when R1 successfully eloped from the building without the alarm sounding and was found by staff outside, unharmed, approximately 15 minutes later, the facility failed to identify malfunctioning alarm system which resulted in subsequent elopements by R2. The administrator, Director of Nursing (DON), nurse manager, and social…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to comprehensively assess sling/harness sizes according to manufacturer's instructions to ensure safe transfers for 2 of 2 residents (R1 and R4) who utilized mechanical lifts sit to stand lift and full body mechanical lifts for transfers. Findings include: R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1's cognition was intact, with diagnoses of hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (stroke), unspecified dementia, diabetes, history of falling, and seizure disorder. Further indicated an impairment in range of motion (ROM) on one side of upper and lower extremities and was dependent with transfers with use of mechanical lift.R1's care plan revised 3/28/25, identified a focus of activities of daily living (ADL)'s: R1 had an ADL self-care performance deficit related to hemiplegia. Goal revised 10/21/25, will maintain current level…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to comprehensively assess each fall to identify and analyze causal factors for potential root cause in order to determine individualized interventions to prevent or decrease the risk for future falls for 1 of 3 residents (R2) reviewed for falls.Findings include: R2's Fall Risk Evaluation dated 6/12/25, identified R2 had 1-2 falls in the past 3 months, had intermittent confusion, was ambulatory and continent. R2 had balance problem while standing and walking and required the use of assistive devices. R2 currently takes 3-4 high risk medications. R2 was at risk for falls, with a goal to be free of falls. Interventions: assist R2 with ambulation and transfers utilizing therapy recommendations, determine ability to transfer, and if fall occurs alert provider.R2's quarterly minimum data set (MDS) dated [DATE], identified R2's cognition was intact, and had diagnoses of Lewy body dementia (a progressive condition characterized by dementia,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-26 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to develop an individualized toileting program to maintain or improve bowel/bladder continence for 1 of 3 residents (R2) reviewed for falls. Findings includeR2's quarterly minimum data set (MDS) dated [DATE], identified R2's cognition was intact, and had diagnoses of Lewy body dementia (a progressive condition characterized by dementia, parkinsonism, and fluctuations in attention and alertness, along with other symptoms like hallucinations and problems with movement), non-Alzheimer's dementia, anxiety and diabetes. R2 required extensive assist of 1 person for transfers, toileting and toileting hygiene and was frequently incontinent of bladder and occasionally incontinent of bowel.In review of R2's record there was no indication a comprehensive bowel and bladder assessment was completed. R2's care plan revised 6/5/25, identified a focus with activities of daily living (ADL) performance deficit related to disease process. Goal revised 8/5/25,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-08-07 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and document review, the facility failed to ensure food stored in the refrigerators were labeled and dated appropriately. This deficient practice had the potential to affect 35 residents who received food from the refrigerators. Findings include: During an initial kitchen tour on 8/5/25 at 10:15 a.m., the large walk-in refrigerator contained an undated plastic container 1/2 full of soup. The refrigerator in the kitchen prep area contained an undated 3/4 full plastic container of potato salad and an undated plastic container 1/4 full of diced ham cubes. [NAME] (C)-A was unaware how old the soup was. C-A was unavailable to confirm date of potato salad or ham cubes. During a subsequent tour and interview on 8/7/25 at 11:01 a.m., dietary manager (DM)-A, indicated the soup, ham cubes, and potato salad had been removed from the refrigerators. Initial tour findings were discussed with DM-A. DM-A confirmed the soup, potato salad, and ham cubes were discarded on 8/6/25. DM-A stated leftovers are good for 48 hours and packaged foods are good 1 week after…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-07 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to provide completed Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN CMS 1005) to 1 of 3 residents (R6) reviewed whose Medicare Part A coverage ended and then remained in the facility. Finding include: R6's census record indicated R6's payer source changed to private pay on 5/23/25 and R6 remained in the facility. R6's face sheet indicated R6's primary payer source is private pay with a secondary payer source as Medicare B. R6's Notice of Medicare Non-coverage (NOMNC) form indicated R6's last covered day was 5/22/25. The form indicated verbal consent was obtained from R6's responsible party on 5/19/25. The form was signed by the responsible party on 5/22/25. R6's medical record lacked evidence a SNFABN form had been provided to explain the estimated cost per day or provide rationale or explanation of the extended care services or items to be furnished, reduced, or terminated. During an interview on 8/06/25 at 1:48 p.m., R6's responsible party (FM)-A confirmed R6 was private pay. FM-A confirmed receipt and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-05-27 · tag F0836 — widespreadEnsure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and 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 and document review, the facility failed to be in compliance with the supplemental nursing service agency (SNSA) requirements when the facility obtained nursing services from Swenswen Staffing, LLC (an SNSA) which was not registered with the commissioner as required. This had the potential to affect all 34 residents of the facility who received services from the supplemental staff. Findings include: Review of the SNSA website on [DATE], did not identify [NAME] Staffing, LLC as being registered with the commissioner as required. Email communication sent on [DATE] at 3:09 p.m., the staffing coordinator (SC) verified that Swenswen Staffing had provided staff in the facility in the past month. Review of the staffing schedules from [DATE] through [DATE], verified that Swenswen Staffing, LLC provided supplemental nursing staffing to the facility on the following days: -[DATE] nursing assistant 6:00 p.m. to 6:30 a.m. -[DATE] trained medication aide 1:00 p.m. to 2:00 p.m. -[DATE] trained medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-05-27 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
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 review and update the facility assessment to identify the facility's staffing plan for number of staff needed to ensure sufficient qualified staff were available to meet residents' needs. Findings include: In an email dated 5/19/25 at 5:50 p.m., the administrator noted overnight staff at the facility also worked at the assisted living facility. She noted this was an oversight if that isn't listed in the facility assessment and she would work on getting it corrected as soon as possible. In a subsequent email at 6:02 p.m., the administrator indicated there was a tracking log and provided an hours log of nursing home staff covering at the assisted living (AL) titled AL Filling In Time Book. Facility document titled AL Filling in Time Book was a log book with dated entries from 3/9/25 through 5/19/25. The log directed staff: Please write down times for the following: counting meds, rounds, any call lights/calls you get, falls, potential emergencies. Any…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-27 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to report an elopement immediately to the administrator and to the State Agency within 2 hours for 1 of 1 resident (R1) who had eloped from the facility. Findings include: R1's face sheet dated 5/28/25, identified diagnoses of dementia (decline in mental ability and memory), delirium (a temporary state of mental confusion), and history of falling. R 1's Minimum Data Set (MDS) dated 2/6 /25, identified R1 needed supervision for transfers and had severe cognitive impairment. R1's elopement care plan focus dated 2/6/25, identified R1 was at risk for elopement related to history of attempts to leave the facility unattended. Interventions of wandergard on left wrist, encourage to attend activities during highest wandering times (late afternoon/evening), and distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. R1's progress note dated 5/8/25 at 7:45p.m., identified R1 had been observed wandering outside of the facility, R1 had a Wanderguard (a wander…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-27 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect wander/elopement alarm use for 1 of 2 residents (R1) reviewed for MDS accuracy. Findings include: R1's quarterly MDS assessment dated [DATE], included section P0200: Alarms with alarm type wander/elopement alarm. The wander/elopement alarm was coded 0 indicating it was not used during the look-back period. R1's Elopement Risk assessment dated [DATE], indicated R1 had a Wanderguard placed on her right wrist. The analysis section noted for the assessment reference date (ARD) of 1/31/25 through 2/6/25, information was collected per review of documentation, observation, and interviews with direct care staff and resident. The analysis further noted, is at risk to wander or elope from facility. Wanderguard in place right wrist. Placement and proper function checked daily. R1's elopement care plan dated 8/28/24, identified she was an elopement risk. Intervention dated 8/28/24,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-05-30 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to ensure that in the absence of a full-time registered dietician (RD), the dietary manager (DM) was certified to oversee nutrition and food services. This had potential to affect all 32 residents who resided in the facility. Findings include: During an interview on 5/28/24 at 5:24 p.m., dietary manager (DM)-D stated she had been employed at the facility for about a year and was not a certified dietary manager. DM-D stated she had been talking about taking a course but didn't know which course to take. DM-D stated she had recently received her ServSafe certificate. During a telephone interview on 5/29/24 at 4:30 p.m., registered dietician (RD)-E stated she was aware DM-D did not meet the required credentials for dietary manager. RD-E stated she was at the facility every four to six weeks, otherwise worked online with staff to oversee dietary operations, conduct resident assessments and evaluations. RD-F stated she was aware the administrator had been encouraging DM-D to obtain the required credentials. During an interview…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · Fcited before2024-05-30 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information, including information for licensed nursing staff, based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed - FY (fiscal year) Quarter 1 2024, (October 1 - December 31), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: The CMS payroll-based journal (PBJ) staffing data report indicated the following: Failed to have licensed nursing coverage 24 hours/day on the following dates: 12/16/23, 12/17/23, 12/30/23, 12/31/23. On 5/29/24 at 2:04 p.m., health unit coordinator (HUC)-A, who was known as the facility scheduler, stated she was responsible for the nurse staff schedules. HUC-A stated the staff schedule ensured a licensed nurse was scheduled each shift (days, evenings, and nights) and 24 hours every day. Utilizing nursing staff schedules from 2023, and for each infraction date, HUC-A identified a licensed nurse by name and title, and verified a licensed nurse…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-08-10 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and document review, the facility failed to ensure it stored, prepared, and served food in accordance with professional standards for food safety. This could affect all 31 residents at the facility. Findings include: Observation and interview on 08/07/23 at 12:10 p.m., during the initial kitchen tour, revealed the handwashing sink in the large main kitchen closest to the kitchen area was lacking soap and paper towels. The dietary manager (DM) indicated maintenance or housekeeping took care of changing soap and paper towels, not the kitchen staff. Observation of the ice machine on 08/07/23 at 12:10 p.m., in the main kitchen near the sink, revealed no record or log of cleaning the ice machine. During interview at the time of the observation, the DM stated she would get the records from maintenance. Interview with the maintenance director (MD) on 08/08/23 at 10:50 a.m., MD stated he had no records or logs of cleaning the ice machine as a service company had been cleaning the ice machine. He did not think it had been serviced since it was installed.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-08-10 · tag F0835 — failed to run the facility competently — widespreadAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility's administrator failed to provide adequate oversite and resources to meet the needs of the residents by failing to ensure kitchen equipment was maintained and functioning, nutritive therapeutic diets were provided, and an effective quality assurance process improvement (QAPI) plan was implemented to identify quality concerns, implement quality improvements measures, and monitor for improvement of identified concerns were maintained. This had the potential to affect all 33 residents who reside in the facility. F803: Based on observations, interviews, and document review, the facility failed to ensure menus were followed, met the nutritional needs of the residents, and were reviewed by the facility Registered Dietitian (RD). This has the potential to affect all 33 residents. F812: F687: Based on interview and document review, the facility failed to maintain a quality assessment and assurance (QAA)/quality assurance process improvement (QAPI) committee that was effective in identifying, implementing actions, and continued monitoring…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-08-10 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespreadHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to implement a comprehensive Quality Assurance and Performance Improvement (QAPI) program that identified concerns with care in the facility were identified reviewed to maintain acceptable levels of performance and continually improved. This had the potential to affect 33 residents residing in the facility. Findings include: The facility's QAPI meeting minutes for the past three meetings was requested, however was not provided. Documentation and evidence of the facility's ongoing performance improvement activities was requested, however was not provided. Documentation and evidence of a recent performance improvement plan (PIP) was requested, however was not provided. When interviewed on 8/10/23 at 11:19 a.m., the administrator was unable to provide QAPI meeting minutes or documentation ongoing quality improvement activities. The administrator acknowledged the QAPI team was not able to get started on any work as there had been some changes in nursing and kitchen leadership. The administrator stated there had been some…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-08-10 · tag F0867 — failed to act on quality-improvement findings — widespreadSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to maintain a quality assessment and assurance (QAA)/quality assurance process improvement (QAPI) committee that was effective in identifying, implementing actions, and continued monitoring to ensure residents received nutritive therapeutic diets and the facility kitchen had sanitary and functioning equipment. This deficient practice had the potential to affect all 33 residents currently residing in the facility. Findings include: The Certification and Survey Provider Enhanced Reports (CASPER)-3 (assessment data was converted to quality measures (QM) to evaluate nursing home's performance) dated 8/3/23, identified the following prior deficiency by month and year: -F812-Food Procurement, Store/Prepare/Serve Sanitary conditions were cited on prior survey 3/23/22, and was cited at a scope and severity (S&S) of an E. The facility's QAPI meeting minutes for the past three meetings was requested however was not provided. Records of communication or email regarding maintenance on the facility dishwasher and ovens was requested…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-08-10 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure staff were following standard precaution guidelines to prevent the spread of infection by wearing personal protective equipment (PPE), while processing contaminated linens. This had the potential to affect all 33 residents who resided within facility. Findings include: On 8/9/23 at 2:19 p.m., nursing assistant (NA)-A provided a tour of a soiled utility room and described the process for gathering, sorting, and bagging of clothes and linens, NA-A stated soiled clothing and linens had to be rinsed out in the hopper sink located in the soiled utility room. NA-A stated protective eyewear and latex gloves needed to be worn when operating the hopper. NA-A further stated gowns were not donned when the hopper was used, and gowns were not available in the soiled utility room. On 8/09/23 at 2:42 p.m., NA-B provided a tour of a second soiled utility room and described the process for gathering, sorting, and bagging of clothes and linens, NA-B stated soiled clothing and linens had to be rinsed out in the hopper sink located in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-08-10 · tag F0908 — failed to keep essential equipment working — widespreadKeep all essential equipment working safely.
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 essential kitchen equipment was maintained in operating condition. This could affect all 31 residents. Findings include: Observation of the kitchen equipment during the initial tour on 08/07/23 at 11:50 a.m., revealed the convection oven located in the main kitchen had a sign on the front door indicating the device was out of order. A second oven in the main kitchen with six burners next to the convection oven had the oven door propped open with tape. The oven door would not close and could not be used Observation on 08/07/23 at 11:55 a.m., revealed a third oven in the main kitchen, one with two ovens, a griddle on top on one side and six burners on top on the other side, revealed the oven to the right side burned too hot for all food placed onto it and the oven on the left cooked too slow requiring over twice the amount of time to cook one item. Observation of one sink near the walk-in refrigerator/freezer on 08/07/23 at 12:00 p.m., revealed one of two sinks connected had a large hole where 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.
- Potential for harm · F2023-08-10 · tag F0924 — widespreadPut firmly secured handrails on each side of hallways.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interview, the facility failed to ensure handrails were equipped on both sides of the corridor for two corridors. This has the potential to affect 15 residents. Findings include: Observation on 08/08/23 at 10:25 a.m., revealed the lower-level therapy area corridor was not equipped with handrails on either side of the corridor. The corridor was 102 feet from the elevator past the therapy area to the exit door and eight feet wide. Observation on 08/10/23 at 12:15 p.m., revealed a small 10 foot long by eight feet wide corridor leading from the main dining room on the upper level and the first floor to the main corridor was not equipped with handrails on either side of this corridor. Residents in the dining room use the corridor to access their bedrooms. Interview on 08/09/23 at 7:50 a.m., the occupational therapy aide (OTA), indicated therapy walked residents in the lower-level corridor without handrails. OTA stated, it would be nice if we had handrails downstairs. Interview on 08/10/23 at 12:20 p.m., the administrator stated she did not notice the lack 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.
- Potential for harm · E2023-08-10 · tag F0803 — failed to meet residents' dietary needs — patternEnsure 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
Based on observations, interviews, and document review, the facility failed to ensure menus were followed, met the nutritional needs of the residents, and were reviewed by the facility Registered Dietitian (RD). This has the potential to affect all 33 residents. Findings include: Review of the facility menus for the week of 08/05/23 to 08/11/23, provided by the dietary manager (DM) revealed the facility menu lacked a low sodium diet, diabetic diet, and finger food or bite size diets. Review of the physician order sheets in the electronic medical record (EMR) and the diet list provided by the DM from physician orders, the facility currently had physician orders for four residents on diabetic diets, seven on finger or bite size foods, and two residents on low sodium diets for which there were no menus. Observation of the meal service on 08/07/23 at 5:00 p.m., revealed the presence of menu items of turkey ala king, a mixed vegetable diced and minced, and mashed potatoes. None of the items provided were prepared for finger foods, low sodium, or diabetic diets. The four residents served…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-10 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure 1 of 1 resident (R12), admitted during the 2022/2023 influenza season (October 1 through March 31) was offered the influenza vaccine in accordance with the Center of Disease Control (CDC) recommendation. Findings include: R12's admission Minimum Data Set (MDS) dated [DATE], indicated R12 was cognitively intact and was admitted to the facility on [DATE]. R12's face sheet dated 01/12/23, indicated diagnoses included, ataxia (loss of control of body movements) hypertension, bifascicular block (abnormal heart beat), and polyneuropathy (peripheral nerve damage). R12's Immunization Report dated 8/10/23, indicated R12 did not receive the influenza vaccine while at the facility, and his medical record lacked evidence the influenza vaccine was offered or contraindicated. During interview on 8/10/23, at approximately 1:00 p.m., the DON acknowledged R12's record lacked evidence the influenza vaccine was offered or declined. The facility's Influenza…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2025-08-07 · tag F0628 — widespreadProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to notify the Ombudsman of transfers and discharges.During the survey documentation review and preparation process, the designated ombudsman was notified of the upcoming facility survey. Per electronic communication on 8/1/2025 at 10:38 a.m., ombudsman stated she had not received any notifications from the facility about transfers and discharges.During interview on 8/7/25 at 8:57 a.m., social worker (SW) stated she does keep track of admissions, discharges, and transfer. SW stated she was unaware she needed to send the admissions, discharges, and transfer notifications to the ombudsman. SW confirmed she had not sent the admissions, discharges, and transfer to the ombudsman. During interview on 8/7/25 at 9:53 a.m., administrator stated the SW is responsible for keeping a log of the facility admissions, discharges, and transfers. Administrator stated she is unaware if the SW had submitted the admissions, discharges, and transfer to the designated ombudsman. Administrator confirmed she had not sent the facility admissions,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2025-05-27 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to post accurate data reflecting the total number and actual hours worked per shift by nursing staff directly responsible for resident care on a daily basis. This had the potential to affect all 34 residents residing in the facility and their visitors who may wish to review the information. Findings include: The facility's nurse staff posting form with date revised 4/17/25, included two pages for each calendar day. The first, titled [Facility] Nursing Schedule, included the following information: Nursing staff roles/titles (nurse, charge nurse, trained medication aide (TMA), nursing assistant (NA), and nurse on-call); names of staff filling the specific role for a given shift; scheduled hours of the shift with start time and end time. The second, titled Report of Nursing Staff Directly Responsible for Resident Care, included the date and daily census as well as a list identifying position (registered nurse (RN), licensed practical nurse (LPN), TMA, and NA), shift worked, hours (number of staff who worked the specified 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.
- No harm found · Ccited before2025-05-27 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review the facility failed to submit accurate and/or complete data for staffing information based on payroll and other verifiable and auditable data during 1 of 1 quarter (Quarter 2) reviewed, to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. This had the potential to affect all 34 residents of the facility who received services from the supplemental staff. Findings include: CMS CASPER Report 1702S titled Staffing Summary Report for dates 1/1/25 through 3/31/25, was a Payroll Based Journal (PBJ) report and included a summary of staffing hours listed by job title. The reported identified the following total nursing staff hours for Quarter 2: - Certified nurse aide (nursing assistant, NA), 5,491.52 hours - Registered nurse (RN), 2,393,98 hours - Licensed practical/vocational nurse (LPN), 2,018.75 - RN director of nursing (DON), 488.00 - Medication aide/technician (trained medication aide, TMA), 131.00 In an email dated 5/19/25 at 5:50 p.m., the administrator noted the facility's overnight staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$28,321 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $28,321 — penalty dated 2025-05-27
- Medicare payment denial — starting 2025-06-25 for 367 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 ST. FRANCIS HEALTH SERVICES — 14 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.8 | +0.2 vs chain |
| Health inspection | 2 of 5 | 2.2 | -0.2 vs chain |
| Staffing | 5 of 5 | 4.6 | +0.4 vs chain |
| Quality measures | 4 of 5 | 2.9 | +1.1 vs chain |
The other 13 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 / manager | Type | Role | Since |
|---|---|---|---|
| DECKER, CHAD | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2016 |
| EHLERS, DOUGLAS | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2023 |
| GOODNOUGH, JENNIFER | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2021 |
| GRAMM, TIMOTHY | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2023 |
| LAIR, MICHAEL | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| LIENEMANN, STEVEN | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| LUETMER, JOHN | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2021 |
| NELSON, PATRICK | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2020 |
| RENTZ, LAURA | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2024 |
| RENTZ, PAUL | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2021 |
| SCHNEIDER, TODD | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/01/2013 |
| WIESE, LORRAINE | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/25/2017 |
| DRIPPS, DANIEL | Individual | CORPORATE DIRECTOR | since 01/01/2016 |
| PETERSON-DEVRIES, CAMI | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/08/2022 |
| RAW, CAROL | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/16/2005 |
| BACH, CURTIS | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/28/2024 |
| BIG STONE THERAPIES, INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/03/2015 |
| EIDE BAILLY LLP | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/03/2023 |
| ST. FRANCIS HEALTH SERVICES OF MORRIS, INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/01/2025 |
| CASPERS, MEGAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/29/2014 |
| ERICKSON-LINNELL, AMELIA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/28/2025 |
| FRUEHBRODT GLENZINSKI, JUDY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| GILLES, ANTHONY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| HANNEKEN, MICHELLE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/20/2022 |
| HEIN, TAYLAR | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/27/2025 |
| HEJHAL, ROXANNE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/10/2023 |
| HOFMANN, REED | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/08/2023 |
| LETICH, ELIZABETH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/01/2023 |
| LIEN, SHANNON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/28/2010 |
| MARLOW, JINA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/06/2022 |
| PADRNOS, CHUCK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/28/2025 |
| PETERS, TIMOTHY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/31/2019 |
| RENTZ, MARK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/22/2024 |
| RYAN, BEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/07/2012 |
| SALCHOW, AMY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/19/2025 |
| SMOOT, MELISSA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/21/2023 |
| STOCK, KELSEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2022 |
| TEPOVICH, NICHOLAS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/08/2024 |
| THOMPSON, RENEE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/10/2018 |
| TOMOSON, APRIL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/12/2021 |
| WALKER, AMY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/13/2024 |
| BOESEN, LACEY | Individual | ADP OF THE SNF | since 05/07/2024 |
CMS files one row per role, so the 110 rows in the source record cover these 42 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $206K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Minnesota Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 245376. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-07, 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.