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| Deficiency Category | Inspection Date: 12/5/24 Complaint Reporting Period: 5/1/24 - 4/30/25 | Inspection Date: 10/25/23 Complaint Reporting Period: 5/1/23 - 4/30/24 | Inspection Date: 9/29/22 Complaint Reporting Period: 5/1/22 - 4/30/23 |
|---|---|---|---|
| Freedom from Abuse, Neglect, and Exploitation Deficiencies | |||
| Quality of Life and Care Deficiencies | |||
| Infection Control Deficiencies | |||
| Resident Assessment and Care Planning Deficiencies | |||
| Nursing and Physician Services Deficiencies | |||
| Resident Rights Deficiencies | |||
| Nutrition and Dietary Deficiencies | |||
| Pharmacy Service Deficiencies | |||
| Environmental Deficiencies | |||
| Administration Deficiencies |
| Date of last standard health inspection: | 12/5/24Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 5/1/24 - 4/30/25 | 2/25/25Read the full report (PDF) 12/20/24Read the full report (PDF) 9/27/24Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 5/1/24 - 4/30/25 | No infection control inspections |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Minnesota: | |
| Average number of Health Deficiencies in the United States: |
| No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 12/20/24 | 12/19/24 | 3 - Actual harm | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 12/5/24 | 1/17/25 | 2 - Minimal harm or potential for actual harm | Few |
Provide enough food/fluids to maintain a resident's health. | 12/5/24 | 1/17/25 | 2 - Minimal harm or potential for actual harm | Few |
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. | 9/27/24 | 9/20/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | 7/2/24 | 8/2/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 2/25/25 | 2/28/25 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Develop and implement policies and procedures for flu and pneumonia vaccinations. | 12/5/24 | 1/17/25 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 12/5/24 | 1/17/25 | 2 - Minimal harm or potential for actual harm | Many |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 2/25/25 | 2/28/25 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Post nurse staffing information every day. | 12/5/24 | 1/17/25 | 2 - Minimal harm or potential for actual harm | Few |
| No Resident Rights Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | 12/5/24 | 1/17/25 | 2 - Minimal harm or potential for actual harm | Few |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 12/5/24 | 1/17/25 | 2 - Minimal harm or potential for actual harm | Many |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
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. | 12/5/24 | 1/17/25 | 2 - Minimal harm or potential for actual harm | Few |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | 12/5/24 | 1/17/25 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are free from significant medication errors. | 7/2/24 | 8/2/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure medication error rates are not 5 percent or greater. | 12/5/24 | 1/17/25 | 2 - Minimal harm or potential for actual harm | Few |
| No Environmental Deficiencies were found during this inspection period. |
| No Administration Deficiencies were found during this inspection period. |
| Date of last standard health inspection: | 10/25/23Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 5/1/23 - 4/30/24 | 2/29/24Read the full report (PDF) 11/9/23Read the full report (PDF) 10/19/23Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 5/1/23 - 4/30/24 | No infection control inspections |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Minnesota: | |
| Average number of Health Deficiencies in the United States: |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Respond appropriately to all alleged violations. | 10/19/23 | 11/29/23 | 2 - Minimal harm or potential for actual harm | Some |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 11/9/23 | 12/6/23 | 2 - Minimal harm or potential for actual harm | Few |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 10/19/23 | 11/29/23 | 2 - Minimal harm or potential for actual harm | Some |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 10/25/23 | 11/29/23 | 1 - Potential for minimal harm | Many |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 2/29/24 | 3/22/24 | 2 - Minimal harm or potential for actual harm | Few |
Respond appropriately to all alleged violations. | 2/29/24 | 3/22/24 | 2 - Minimal harm or potential for actual harm | Few |
Respond appropriately to all alleged violations. | 11/9/23 | 12/6/23 | 2 - Minimal harm or potential for actual harm | Few |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 11/9/23 | 12/6/23 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide activities to meet all resident's needs. | 10/25/23 | 11/29/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 10/25/23 | 11/29/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 2/29/24 | 3/22/24 | 3 - Actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 2/29/24 | 3/22/24 | 3 - Actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 10/19/23 | 11/29/23 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide and implement an infection prevention and control program. | 10/25/23 | 11/29/23 | 2 - Minimal harm or potential for actual harm | Many |
| No Resident Assessment and Care Planning Deficiencies were found during this inspection period. |
| No Nursing and Physician Services Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 10/25/23 | 11/29/23 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | 10/25/23 | 11/29/23 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | 2/29/24 | 3/22/24 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | 10/25/23 | 11/29/23 | 2 - Minimal harm or potential for actual harm | Some |
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | 10/25/23 | 11/29/23 | 2 - Minimal harm or potential for actual harm | Few |
| No Pharmacy Service Deficiencies were found during this inspection period. |
| No Environmental Deficiencies were found during this inspection period. |
| No Administration Deficiencies were found during this inspection period. |
| Date of last standard health inspection: | 9/29/22Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 5/1/22 - 4/30/23 | 3/17/23Read the full report (PDF) 9/29/22Read the full report (PDF) 6/17/22Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 5/1/22 - 4/30/23 | 6/17/22Read the full report (PDF) |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Minnesota: | |
| Average number of Health Deficiencies in the United States: |
| No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide care and assistance to perform activities of daily living for any resident who is unable. | 9/29/22 | 11/10/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe, appropriate pain management for a resident who requires such services. | 9/29/22 | 11/10/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 3/17/23 | 4/14/23 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Implement a program that monitors antibiotic use. | 9/29/22 | 11/10/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 6/17/22 | 7/20/22 | 2 - Minimal harm or potential for actual harm | Few |
| No Resident Assessment and Care Planning Deficiencies were found during this inspection period. |
| No Nursing and Physician Services Deficiencies were found during this inspection period. |
| No Resident Rights Deficiencies were found during this inspection period. |
| No Nutrition and Dietary Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
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. | 9/29/22 | 11/10/22 | 2 - Minimal harm or potential for actual harm | Few |
| No Environmental Deficiencies were found during this inspection period. |
| No Administration Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 12/20/24 | 12/19/24 | 3 - Actual harm | Few |
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. | 9/27/24 | 9/20/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | 7/2/24 | 8/2/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 2/25/25 | 2/28/25 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 2/25/25 | 2/28/25 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are free from significant medication errors. | 7/2/24 | 8/2/24 | 2 - Minimal harm or potential for actual harm | Few |
Respond appropriately to all alleged violations. | 10/19/23 | 11/29/23 | 2 - Minimal harm or potential for actual harm | Some |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 11/9/23 | 12/6/23 | 2 - Minimal harm or potential for actual harm | Few |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 10/19/23 | 11/29/23 | 2 - Minimal harm or potential for actual harm | Some |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 2/29/24 | 3/22/24 | 2 - Minimal harm or potential for actual harm | Few |
Respond appropriately to all alleged violations. | 2/29/24 | 3/22/24 | 2 - Minimal harm or potential for actual harm | Few |
Respond appropriately to all alleged violations. | 11/9/23 | 12/6/23 | 2 - Minimal harm or potential for actual harm | Few |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 11/9/23 | 12/6/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 2/29/24 | 3/22/24 | 3 - Actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 2/29/24 | 3/22/24 | 3 - Actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 10/19/23 | 11/29/23 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | 2/29/24 | 3/22/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 3/17/23 | 4/14/23 | 2 - Minimal harm or potential for actual harm | Few |
Implement a program that monitors antibiotic use. | 9/29/22 | 11/10/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 6/17/22 | 7/20/22 | 2 - Minimal harm or potential for actual harm | Few |
| This nursing home has not been cited for any deficiencies on infection control inspections in the last 3 years. |