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The Meadows On University

1315 S University Dr, Fargo, ND 58103 · For profit - Limited Liability company · 95 certified beds · (701) 237-3030 Medicare & Medicaid certified

Call the home — (701) 237-3030 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation$41,041 in federal fines
Insights

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

Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $41,041 in federal fines (most recent 2025-04-09)
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (65%) runs well above the national median (45%)

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
Urgent care / clinic
1702 University Dr S · (701) 364-3300 · Call to confirm hours
Pharmacy
1521 University Dr S · (701) 232-8690 · Call to confirm hours
Grocery
Supervalu0.2 mi
1433 University Dr S · (701) 237-9481 · Call to confirm hours
Park
1451 6th St S · (701) 499-6060 · Typically dawn to dusk
Place of worship
1330 University Dr S · (701) 235-6603

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

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased16.1%19.8%15.4%typical
Long-stay residents who lose too much weight8.3%5.8%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%1.6%0.9%better
Long-stay residents with a urinary tract infection3.4%2.6%2.0%worse
Long-stay residents with depressive symptoms1.9%4.4%6.5%better
Long-stay residents who were physically restrained0.0%0.2%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.6%5.1%3.3%better
Long-stay residents whose ability to walk worsened27.0%17.6%16.1%worse
Long-stay residents on antianxiety or hypnotic medication18.2%17.4%18.9%typical
Long-stay residents given the seasonal flu vaccine89.1%98.8%95.3%typical
Long-stay residents with pressure ulcers9.1%4.9%4.7%worse
Long-stay residents with worsening bladder/bowel control20.7%24.9%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table2.9%22.7%17.1%better
Short-stay residents who newly got an antipsychotic medication1.6%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine79.5%88.3%79.4%typical
Short-stay residents rehospitalized after admission25.0%19.9%22.6%worse
Short-stay residents with an outpatient ER visit11.9%11.4%12.0%typical
Long-stay hospitalizations per 1,000 resident days2.181.491.67worse
Long-stay outpatient ER visits per 1,000 resident days1.631.861.80typical

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.

56.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 34 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

56.3%U.S. median 51.5%
Got home and stayed home
10.0%U.S. median 10.7%
Went back to hospital
47.6%U.S. median 56.6%
Met the expected recovery
0.91U.S. median 0.31
Therapy hours / resident / day
0.49hours / resident / day
Physical therapy
0.35hours / resident / day
Occupational therapy
0.08hours / resident / day
Speech therapy

Met the expected recovery: 47.6% 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 42 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 0.91 therapist hours per resident per day in 2026Q1 — more than 96% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF56.3%CMS range 39.3–69.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.0%CMS range 6.2–14.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge47.6%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge23.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge35.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.5%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened9.2%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.4%CMS range 4.0–11.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.071.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.67
RN hours/ resident / day
0.68
LPN hours/ resident / day
2.36
Aide hours/ resident / day
3.71
Total nurse hours/ resident / day
0.63
RN hoursweekends
65.0%
Total nursing turnover
91.7%
RN turnover

How full it usually is: this home is certified for 95 beds and averages 68.7 residents a day — about 72% occupied, or roughly 26 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 3.71 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.36 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 3.33 hrs/resident/day on weekends vs 3.87 on weekdays — 14% thinner on weekends. RN hours go from 0.69 to 0.63 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 65% is well above the national median of 45%.

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

Inspection trend

8
deficiencies at the latest standard inspection (2025-04-09)
4
at the previous standard inspection (2024-02-08)

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.

ABCDEFGHIJKL

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

31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.

  • Actual harm · G2025-04-09 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, review of facility policy, and staff interview, the facility failed to maintain acceptable parameters of nutritional status for 1 of 1 sampled resident (Resident #47) with weight loss. Failure to monitor/document intakes accurately and provide encouragement and assistance with meals and supplements resulted in a significant weight loss. Findings include: Review of the facility policy titled Weight Assessment and Intervention occurred on 04/09/25. This policy, dated September 2008, stated, . The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. 3. The Dietitian will review the weight record weekly to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. Provider will be updated with significant weight changes. Analysis . 1. Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the: . b. Approximate calorie,…

    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 · F2026-06-10 · tag F0725 — failed to have enough nursing staff — widespread
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of resident council meeting minutes, review of facility policy, confidential resident, family, and staff interviews, the facility failed to ensure sufficient nursing staff and related services are available to meet the residents' need for 4 of 18 sampled residents (Resident E, J, N, and P), and 12 supplemental residents (Resident A, B, C, D, F, G, H, I, K, L, M, and O) who required staff assistance. Failure to provide sufficient staffing does not promote each resident's rights, physical, mental, and psychosocial well-being, and/or provide a safe environment for all residents. Findings Include: Review of facility policy titled Call lights: Accessibility and Timely Response occurred on 06/10/26. This policy, dated 06/15/25, stated, . All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate person should be notified. Review of resident council meeting minutes dated 12/15/25, 02/23/26, 03/20/26, and 04/17/26, identified residents reported long call light…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-06-10 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, review of facility policy, and resident and staff interviews, the facility failed to provide the necessary services for 4 of 18 sampled residents (Resident #1, #10, #30, and #55) who required assistance with bathing. Failure to provide bathing as scheduled may result in poor personal hygiene and decreased self-esteem. Findings include: Review of facility policy titled Activities of Daily Living occurred on 06/10/26. This policy, dated May 2025, stated, . A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. - Review of Resident #1's medical record occurred on all days of survey. The current care plan stated, has impaired physical functioning r/t [related to] fatigue and weakness . Shower/bathe . A [assist] [of] 1 . During an interview on 06/08/26 at 4:20 p.m., Resident #1 stated he/she requested two showers a week, but usually only receives one a week. Review of Resident #1's bathing/shower record identified showers scheduled twice weekly on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-06-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interview, the facility failed to provide adequate housekeeping services to prevent accidents on 1 of 4 days of survey (06/07/26). Failure to clean standing water from the floor placed residents, staff, and visitors at risk of falls and injury.Findings include: -Observation on 06/07/26 at 11:05 a.m. showed a trail of water on the floor extending down the central hallway. Observation of staff and residents walking in hallway. The water remained on the floor until 11:48 a.m. (43 minutes). -Observation on 06/07/26 at 11:30 a.m. showed water dripped from the ceiling air-conditioning unit into a bucket near the Dakota Dining Room. Observation showed a puddle of water surrounding the bucket and extended under and into the doorway threshold of the Dakota Dining Room. Staff propped a wet floor sign against the wall. Observation of staff and residents walking in hallway. The water remained on the floor until 1:10 p.m. (One hour and 40 minutes) -Observation on 06/07/26 at 2:28 p.m. showed water continued to drip into a bucket from the ceiling air-conditioning…

    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 · Ecited before2026-06-10 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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, review of facility policy, and staff interview, the facility failed to ensure food items were stored and monitored in a safe manner in 1 of 1 kitchen and 1 of 1 kitchenette observed. Failure to properly store, label, date, monitor, and discard food items may result in the consumption of unsafe food and place residents at risk for foodborne illness.Findings include:Review of facility policy titled, Monitoring of Cooler/Freezer Temperatures occurred on 06/10/26. This policy, dated 06/05/25, stated, . Refrigerated food shall be labeled, dated, and monitored so that it is used by the use by date . discarded . Review of facility policy titled, Foods Brought by Family/Visitors occurred on 06/10/26. This undated policy stated, . Food brought . will be labeled and stored in a manner that is clearly distinguishable . Containers will be labeled with the resident's name, the item and the 'use by' date. The food service staff will discard perishable foods on or before the 'use by' or three (3) days from opening date. will discard any foods . show obvious signs of potential…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · Ecited before2026-06-10 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, review of facility policies, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 7 sampled residents (Resident #2 and #7) observed during cares, 1 of 5 residents observed during medication pass (Resident #19), and one laundry room. Failure to follow infection control standards related to hand hygiene, glove use, medication administration, the use of personal protective equipment (PPE) and enhanced barrier precautions (EBP), and storage of soiled/clean items within the laundry room has the potential to spread infection throughout the facility. Findings Include: Review of the facility policy titled Enhanced Barrier Precautions occurred on 06/09/26. This policy, dated 04/11/25, stated, Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. An order for enhanced barrier precautions will be obtained for residents with any of the following:…

    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 · D2026-06-10 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of Medicare Part A letters/notices, review of facility policy, and staff interview, the facility failed to ensure the resident and/or their representative completed the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) for 2 of 3 residents (Resident #43 and #81) reviewed for termination of Medicare Part A services. Failure to ensure the completion of the SNFABN limited the resident/representative's ability to exercise their rights regarding Medicare Part A services.Findings include:Review of facility policy titled Advance Beneficiary Notices occurred on 06/10/26. This policy, dated 06/25/25, stated, . The facility shall inform Medicare beneficiaries of his or her potential liability for payment. the form shall comply with related instructions and regulations regarding the use of the form. The notice shall . obtain beneficiary or representative signature.- Review of Medicare Part A beneficiary notices identified Resident #43 discharged from Medicare Part A on 05/20/26. The SNFABN failed to identify if the resident/resident's representative…

    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 before2026-06-10 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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, review of facility policy, and resident and staff interviews, the facility failed to provide housekeeping services to maintain a safe, clean, comfortable and homelike environment for 4 of 4 days of survey. Failure to ensure the resident environment and equipment are kept clean and sanitary does not promote a homelike living environment or enhance the residents' quality of life. Findings include: Review of the facility policy titled Safe and Homelike Environment occurred on 06/10/26. This policy, dated May 2025, stated, . In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment . Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. - Observation on all days of survey showed large amounts of food debris on Resident #3's wheelchair and stains on the padded footrests. During an interview on 06/10/26 at 1:40 p.m. an administrative staff member (#1) stated she…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-10 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and resident and staff interviews, the facility failed to review and revise care plans to reflect the residents' current status for 2 of 18 sampled residents (Resident #1 and #30). Failure to update care plans limited the staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Comprehensive Care Plans occurred on 06/10/26. This policy, dated May 2025, stated, . The comprehensive care plan will be reviewed and revised by the interdisciplinary team . - Review of Resident #1's medical records occurred on all days of survey. A progress note dated 5/26/26, stated, . The resident informed this writer that, moving forward, he only wishes to see his sister in open areas of the building. and the resident has expressed that no further information is to be shared with her.Resident #1's care plan failed to include choices related to his sister's involvement with his care. - Review of Resident #30's medical record occurred on all days of survey. The care plan stated, . has potential for complications/injury…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-10 · 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

    Based on observations, record review, review of facility policy, and staff interview, the facility failed to provide care and services for 1 of 1 supplemental resident (Resident #57) observed with a wound dressing. Failure to follow physician's orders regarding dressing changes may result in delayed treatment, infection, and increased wound complications. Findings include:Review of the facility policy titled Clean Dressing Change occurred on 06/10/26. This policy, dated May 2025, stated, . It is the policy of this facility to provide wound care in a manner to decrease potential for infection . Physician's orders will specify type of dressing change and frequency of changes. Assure dressing is labeled with initials and date.Review of Resident #57's medical record occurred on June 7, 9 and 10, 2026. A physician's order dated 06/02/26 stated, Skin tear to right lower extremity. Cleanse area, pat dry, keep steri strips intact. Cover with 4x4 gauze and secure with tape QD [every day] and prn [as needed].Observation on 06/07/26 at 4:30 p.m. showed an occlusive dressing to Resident #57'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 plan of correction
  • Potential for harm · Dcited before2026-06-10 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, review of facility policy, and review of manufacturer's instructions, the facility failed to ensure a medication error rate of less than five percent for 2 of 25 medications observed during medication administration. Two medication errors occurred during staff administration of 25 medications, which resulted in an eight percent error rate. Failure to follow facility policy and pharmacy instructions may inhibit the effectiveness of the medication, cause subtherapeutic levels, and may have a negative impact on the resident's overall health. Findings include:Review of facility policy titled Insulin Pen occurred on 06/10/26. This policy, dated 06/05/25, states, . Prime the insulin pen . With the needle pointing up, push the plunger, watch to see that at least one drop of insulin appears on the tip of the needle.Review of manufacturer instructions for Advair Diskus (dry powder inhaler), occurred on 06/10/26. These instructions, revised March 2026, states, . ADVAIR DISKUS can cause serious side effects, including . fungal infection in your mouth or throat (thrush).…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 20 citations
  • Potential for harm · D2025-12-30 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, review of facility policy, and staff interview, the facility failed to develop a baseline care plan to reflect the needs for 1 of 1 sampled resident (Resident #1) identified as a new admission. Failure to develop and implement a baseline care plan may result in inconsistent and unsafe care for all newly admitted residents. Findings include:Review of the facility policy titled Baseline Care Plan occurred on 12/30/25. This policy, dated 05/05/25, stated, . The baseline care plan will . be developed within 48 hours of a resident's admission. Include the minimum healthcare information necessary to properly care for a resident .Review of Resident #1's medical record occurred on all days of survey and identified an admission date of 12/10/25. The comprehensive assessment, dated 12/12/25, stated, . Transfer - assist x1 (assist of one) . Eating - independently . Toileting - assist x1 .The resident's base line care plan, dated 12/10/25, identified no interventions for specific needs such as transfers, eating, and toilet use. During an interview on 12/31/25 at 10:35…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-04 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 1 sampled resident (Resident #1) on contact precautions. Failure to practice infection control standards related to contact precautions and hand hygiene for staff and residents has the potential to spread infection throughout the facility.Findings include:Review of the facility policy titled Management of C. [Clostridioides] Difficile Infection [a contagious bacterial infection] occurred on 12/04/25. This policy, revised 04/10/25, stated, . All staff are to wear gloves and a gown upon entry into the resident's room and while providing care . Hand hygiene shall be performed by handwashing with soap and water . Encourage/assist residents to wash hands frequently.Review of the facility policy titled Hand Hygiene occurred on 12/04/25. This policy, revised 04/10/25, stated, . If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. For conditions involving 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-09 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure residents received the necessary services to maintain personal hygiene for 6 of 15 sampled residents (Resident #2, #6, #16, #36, #43, and #47) dependent on staff assistance for personal hygiene and dining. Failure to assist residents who cannot perform personal hygiene, position self, or open items at meals may result in poor hygiene, skin issues, weight issues, and decreased self-esteem. Findings include: Review of the facility policy titled Fingernails/Toenails, Care of occurred on 04/09/25. This policy, dated 2018, stated, . The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Review of the facility policy titled Activities of Daily Living (ADLs), Supporting occurred on 04/09/25. This policy, dated 2021, stated, . Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, . including…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-09 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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, review of professional reference, and staff interview, the facility failed to maintain a clean and sanitary kitchen environment for 1 of 1 kitchen. Failure to ensure dishware is stored in a clean area and failure to ensure the floors and warewashing machine are free from food/dust debris has the potential for contamination of food and may result in a foodborne illness to residents, visitors, and staff. Findings include: The 2022 Food and Drug Administration (FDA) Food Code, reviewed 01/08/25, Chapter 4-6, pages 20-21, Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, stated, (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. Observations on 04/09/25 at 10:30 a.m. showed the following in the main kitchen: * Loose debris and dust accumulated on the top of the mechanical warewashing machine. * Visible dry particles and debris on a tray of uncovered bowls located in a…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-09 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to follow standards of infection control and prevention for 5 of 8 sampled residents (Resident #2, #6, #8, #36, and #50) and one supplemental resident (Resident #15) observed during cares. Failure to practice infection control standards related to enhanced barrier precautions (EBP), perineal care, dressing changes, and hand hygiene, has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Enhanced Barrier Precautions occurred on 04/09/25. This undated policy stated, . EBPs employ targeted gown and glove use during high contact care activities . Examples of high-contact care activities requiring the use of gown and glove for EBP include . urinary catheter . wound care (any opening requiring a dressing). Review of the facility policy titled Dressings, Dry/Clean occurred on 04/09/25. This undated policy stated, . Put on clean gloves. Loosen tape and remove soiled dressing. 7. Pull glove…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-09 · 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, review of facility policy, and resident and staff interviews, the facility failed to provide care in a manner that maintained, enhanced, and respected the resident's dignity and individuality for 1 of 15 sampled residents (Resident #6). Failure to honor the resident's request during cares and ensure staff speak respectfully does not promote the resident's self-esteem, preserve the resident's personal dignity, and may affect the resident's psychosocial well-being. Findings include: Review of the facility policy titled Quality of Life - Dignity occurred on 04/09/25. This policy, dated 2018, stated, . Residents shall be treated with dignity and respect at all times. 'Treated with dignity' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self -worth. Staff shall speak respectfully to residents at all times . Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed .…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-09 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy, and resident and staff interviews, the facility failed to ensure reasonable accommodation of needs regarding call lights for 1 of 15 sampled residents (Resident #6). Failure to place call lights within reach may result in an inability for residents to call for help, an increased risk for falls, and discomfort. Findings include: Review of the facility policy titled Call System, Resident occurred on 04/09/25. This undated policy stated, . Each resident is provided with a means to call staff directly for assistance from his/her bed . Review of Resident #6's medical record occurred on all days of survey. Diagnoses included quadriplegia. The care plan stated, . I use an easy call universal quadriplegic call bell [activated by a turn of the resident's head] or soft touch call bell [placed in the resident's hand] while in bed . An annual Minimum Data Set (MDS), dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.…

    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 before2025-04-09 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 15 sampled residents (Residents #4, #26, and #36). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION A: IDENTIFICATION INFORMATION The Long-Term Care Facility RAI User's Manual, revised October 2024, page A-32, stated, . Coding Instructions. Code A, Serious mental illness: if resident has been diagnosed with a serious mental illness . Review of Resident #26's medical record occurred on all days of survey. The record included diagnoses of psychosis, schizotypal disorder, bipolar disorder and psychophysical visual disturbances. A comprehensive MDS, dated [DATE], showed the facility…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-09 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of facility policy, review of professional reference, and resident and staff interviews, the facility failed to provide the necessary care and treatment for 1 of 3 sampled residents (Resident #6) with impaired skin integrity and concerns of incontinence care. Failure to assess, monitor, and treat skin issues in a timely manner may have resulted in a delay of treatment and risk for further skin breakdown. Failure to provide routine incontinence cares (check and change) placed the resident at risk for skin breakdown, poor grooming/hygiene, decreased self-esteem, and urinary tract infections. Findings include: Review of the facility policy titled Skin Breakdown-Clinical Protocol occurred on 04/09/25. This policy, dated 2022, stated, Evaluation and Recognition. the nurse shall describe and document/report the following . Full assessment including skin breakdown location, stage if applicable, length, width and depth . current treatments . The facility failed to provide 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-13 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 1. Based on observation, record review, review of manufacturer's instructions for use, and staff interview, the facility failed to ensure staff followed standards of practice for 1 of 1 resident (Resident #1) who required rapid-acting insulin. Failure to administer rapid acting insulin within the time frame specified by the manufacturer may result in a hypoglycemic (low blood sugar) reaction. Findings include: Review of prescribing information for Humalog insulin (a rapid-acting insulin), found at https://www.humalog.com, occurred on 01/13/25, and stated, Administer HUMALOG . within 15 minutes before a meal or immediately after a meal. Review of Resident #1's medical record occurred on 01/13/25. Physician's orders included Humalog insulin 10 units three times a day. The Minimum Data Set (MDS), dated [DATE], identified dependent on staff for eating, Observations on 01/13/25 showed a nurse (#2) checked Resident #1's blood sugar at 11:57 a.m., obtained a blood glucose reading of 107 milligrams/deciliter (mg/dl),…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-13 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, review of a professional reference, and resident and staff interviews, the facility failed to provide appropriate toileting for 1 of 1 confidential resident (Resident A) who required staff assistance with toileting/check and change. Failure to provide toileting/check and change may result in a loss of dignity and placed the resident at risk for skin breakdown, poor grooming/hygiene, decreased self-esteem, urinary tract infections, and risk for fall and/or injuries. Findings include: Kozier & Erb's Fundamentals of Nursing: Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 892, stated, Fecal and Urinary Incontinence: Moisture from incontinence promotes skin maceration [tissue softened by prolonged wetting or soaking] and makes the epidermis [skin] more easily eroded and susceptible to injury. Digestive enzymes in feces, urea in urine . also contribute to skin excoriation [area of loss of the superficial layers of the skin] . Any accumulation of secretions . is irritating to the skin, harbors microorganisms, and makes…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-13 · 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

    Based on observation, review of facility policy, and resident interviews, the facility failed to serve foods at palatable temperatures for 2 of 2 sampled residents (Resident #1 and #3) who received a meal tray in their room. Failure to serve foods at a temperature acceptable to residents may result in decreased intake, weight loss, and inadequate nutrition. Findings include: Review of the facility policy titled Food Preparation and Service occurred on 01/13/25. This policy, dated November 2022, stated, . Ready to eat foods that require reheating . cooked to at least 135 degrees F [Fahrenheit] for holding for hot service. - Observation on 01/13/25 at 12:45 p.m., showed the CNA (#3) delivered the noon meal to Resident #1. The certified nurses aide (CNA) gave the resident a bite of the fish, the resident spit it out, refused to eat the rest of the food, and stated, The food is cold, I would like warm food. The CNA (#3) removed the tray from the room and returned with a new tray. Resident #1 stated he often receives cold food and asks for a warm food tray. - Observation on 1/13/25 at…

    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 · Dcited before2025-01-13 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 1 supplemental resident (Resident #7) who tested positive for influenza and 1 of 6 sampled residents (Resident #3) observed during cares. Failure to practice infection control standards related to influenza precautions and hand hygiene has the potential to spread infection throughout the facility. Findings include: Review of the facility's policy titled Isolation - Categories of Transmission-Based Precautions occurred on 01/13/25. This policy, revised September 2022, stated, . Droplet Precautions . Masks are worn when entering. Review of the facility's policy titled Handwashing/Hand Hygiene occurred on 01/13/25. This policy, dated August 2019, stated, . Use an alcohol-based hand rub . or . soap . and water for the following situations . Before and after . handling food .Before and after assisting a resident with meals . - Review of Resident #3's medical record occurred on 01/13/25 and identified a foley catheter. Observation on…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-08 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, review of facility policy, professional reference, and resident and staff interview, the facility failed to follow professional standards for 1 of 1 sampled resident (Resident #13) observed during blood glucose testing and insulin administration. Failure to clarify orders regarding the timing of blood glucose testing and administration of sliding scale insulin may result in inaccurate/inconsistent readings and insulin needs. Findings include: Review of a professional online reference Diabetes Education Online - Sliding Scale Therapy https://dtc.ucsf.edu/ Compiled 2007-2024, Diabetes Teaching Center at the University of California, San Francisco, stated, The term 'sliding scale' refers to the progressive increase in the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges. short acting insulin (aspart, glulisine, lispro, Regular) before meals and at bedtime . The bolus insulin is based on the blood sugar level before the meal or at bedtime. Review of Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-08 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, review of facility policy, and staff interview, the facility failed to ensure each resident's medication regimen was free from unnecessary medications for 1 of 3 sampled residents (Resident #11) who received an as-needed (PRN) psychotropic medication. Failure to ensure the provider indicates the duration for the PRN order when documenting the clinical justification for continued use of a PRN psychotropic medication may result in the resident receiving the medication for an excessive duration and/or experiencing adverse side effects related to its use. Findings include: Review of the policy titled Medication Regimen Reviews occurred on 02/08/24. This policy, revised May 2019, stated, . An 'irregularity' refers to the use of medication that is inconsistent with accepted pharmaceutical services standards of practice; is not supported by medical evidence; and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services. Review of Resident #11's medical record occurred on all days of survey. The physician's orders identified an active…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-08 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 2 of 10 residents (Resident #23 and #294) observed during medication administration. Three medication errors occurred during staff administration of 27 medications, resulting in an 11% error rate. Failure to properly administer medications may result in residents receiving an ineffective dose and experiencing adverse reactions. Findings include: Review of the facility policy titled Administering Oral Medications occurred on 02/06/24. This policy, revised October 2010, stated, . Check the label on the medication and confirm the medication name and dose with the MAR [Medication Administration Record]. Check the medication dose. Re-check to confirm the proper dose. Review of Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th ed., Pearson Education, Inc., New Jersey, page 65, stated, Make sure the correct medications are given in the correct dose, by the right…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-08 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and staff interview, the facility failed to ensure appropriate labeling of medications for 2 of 10 residents (Resident #13 and #37) observed during medication administration. Failure to ensure medication cards contain the correct administration information may result in medication errors and adverse drug effects. Findings include: - Observation on 02/06/24 at 8:40 a.m. showed a staff nurse (#3) prepared Resident #13's Humalog insulin pen for the scheduled six units and additional four units per sliding scale. The pen's label stated, Inject 6 units subcutaneous three times a day with meals. The pen's label lacked instructions for sliding scale use. The nurse (#3) verified the resident's Humalog insulin pen was used for both scheduled and sliding scale administration. During an interview on 02/06/24 at 1:00 p.m. an administrative nurse (#1) stated the pharmacy placed stickers on insulin pens indicating Directions changed refer to chart. The nurse (#1) identified the sticker alerted nurses to read the medication administration record (MAR) for…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-09 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 13 sampled residents (Resident #14, #27, and #32) and one supplemental resident (Resident #29). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION J: HEALTH CONDITIONS The Long-Term Care Facility RAI User's Manual, revised October 2019, pages J-24 and J-25, stated, . HOSPICE SERVICES: A program for terminally ill persons . TERMINALLY ILL: Terminally ill means that the individual has a medical prognosis that his or her life expectancy is 6 months or less if the illness runs its normal course. Coding Instructions: . Code 1, yes: if the medical record includes…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-09 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and staff interview, the facility failed to ensure a safe, clean, comfortable, homelike environment for 2 of 5 sampled residents (Resident #20 and #27) on oxygen. Failure to clean personal fans and oxygen concentrator filters does not provide a safe and clean environment and has the potential to place the residents at risk for illness. Findings include: The facility failed to provide a policy/procedure for the cleaning of personal fans and changing/cleaning the oxygen concentrator filters. -Observation on 08/06/23 at 11:18 a.m. showed Resident #20 lying in bed with oxygen being administered via nasal cannula. Observation showed the oxygen concentrator filter covered in dust and debris. Review of Resident #20's medical record occurred on all days of the survey. Diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease, obstructive sleep apnea, and shortness of breath. During an interview on 08/08/23 at 3:07 p.m., an administrative nurse (#1) confirmed staff failed to clean the oxygen concentrator filter and clean 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2026-06-10 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, review of facility policy, and staff interview, the facility failed to ensure posting of resident census on 3 of 4 days of survey (June 7, 2026 - June 9, 2026). Failure to post the resident census may impede the facility's ability to evaluate staffing levels in relation to the number of residents residing in the facility.Findings include:Review of the facility policy titled Nurse Staffing Posting Information occurred on 06/10/26. This policy, dated 05/16/26, stated, . The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: . Facilities current resident census .- Observation on June 7-9, 2026, identified the facility failed to include the resident census number on the nurse staffing information.During an interview on 06/09/26 at 3:30 p.m., an administrative staff member (#1) stated she expected the human resource staff to complete and post a daily census/staffing report.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$41,041 in federal fines across 1 penalty.

  • $41,041 — penalty dated 2025-04-09

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 EDURO HEALTHCARE — 34 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 52.4-1.4 vs chain
Health inspection 1 of 52.4-1.4 vs chain
Staffing 2 of 52.2-0.2 vs chain
Quality measures 2 of 53.1-1.1 vs chain
The other 33 homes this chain runs (chain average 2.4★, per CMS)
1 of 5Bear Creek Nursing And RehabilitationGrapevine, TX 1 of 5Cooney Healthcare And RehabilitationHelena, MT 1 of 5Deer Creek Nursing and RehabilitationWimberley, TX 1 of 5Ennis Care CenterEnnis, TX 1 of 5Greenview Nursing and RehabilitationWaco, TX 1 of 5Lakeshore Village Nursing And RehabilitationWaco, TX 1 of 5Memorial Medical Nursing And RehabilitationSan Antonio, TX 1 of 5Pleasanton North Nursing And RehabilitationPleasanton, TX 1 of 5Richardson Nursing and RehabilitationRichardson, TX 1 of 5Rolling Hills HealthcareBelle Fourche, SD 1 of 5San Antonio North Nursing and RehabilitationSan Antonio, TX 1 of 5Skyline Heights Nursing And RehabilitationBillings, MT 1 of 5The Suites PasadenaPasadena, TX 1 of 5Yellowstone River Nursing And RehabilitationBillings, MT 2 of 5Elkhorn Healthcare And RehabilitationClancy, MT 2 of 5Jourdanton Nursing and RehabilitationJourdanton, TX 2 of 5Keystone Post-AcuteFresno, CA 2 of 5Parkview Nursing and Rehabilitation CenterLockhart, TX 2 of 5Spearfish Canyon HealthcareSpearfish, SD 2 of 5The Suites Rio VistaRio Rancho, NM 3 of 5Cypress Woods Care CenterAngleton, TX 3 of 5Eastern Montana Veterans HomeGlendive, MT 3 of 5Silver Creek Nursing And RehabilitationSan Antonio, TX 4 of 5Copper Ridge Health And Rehabilitation CenterButte, MT 4 of 5Hacienda Oaks At BeevilleBeeville, TX 4 of 5Heritage Trails Nursing And Rehabilitation CenterCleburne, TX 4 of 5Pleasanton South Nursing and RehabilitationPleasanton, TX 4 of 5Prairie Heights HealthcareAberdeen, SD 5 of 5Bangs Nursing And RehabilitationBangs, TX 5 of 5Golden Years Nursing And Rehabilitation CenterMarlin, TX 5 of 5Highland Care CenterHolladay, UT 5 of 5Hurst Plaza Nursing and RehabHurst, TX 5 of 5Southwest Montana Veterans HomeButte, MT

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

Who owns this facility

Owner / managerTypeRoleSince
THOMPSON, CHRISTOPHERIndividualW-2 MANAGING EMPLOYEEsince 07/18/2018
EDURO HEALTHCARE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 07/18/2018

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$7.2M
Net patient revenuemost recent cost report
-21.8%
Operating marginrevenue minus expenses
$363K
Related-party expense4% of expenses
Who pays — share of resident-days
Medicaid 75%Medicare 6%Other / private 19%

About 75% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $363K 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

$554per resident / day
operating cost
$16,846per month
≈ monthly operating cost
$455per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in ND

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the North Dakota Medicaid page.

Typical monthly cost in North Dakota
$11,528/mo
Nursing home (semi-private)
$12,304/mo
Nursing home (private)
$4,729/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 355024. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-09, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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