The Terrace at Crystal LLC

• Star rating

  The CMS overall star rating changed from not rated by CMS to 1 of 5.

• Star rating

  The CMS health inspection star rating changed from not rated by CMS to 1 of 5.

• Star rating

  The CMS staffing star rating changed from not rated by CMS to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from not rated by CMS to 1 of 5.

• Special Focus Facility

  CMS now lists this home as a Special Focus Facility candidate.

• Fine

  CMS changed the fine from August 6, 2024 from $16,349 to $18,146.

• Health citation

  CMS removed citation F0550 from the health inspection on February 13, 2025.

• Health citation

  CMS removed citation F0558 from the health inspection on February 13, 2025.

• Health citation

  CMS removed citation F0565 from the health inspection on February 13, 2025.

• Health citation

  CMS removed citation F0580 from the health inspection on February 13, 2025.

• Health citation

  CMS removed citation F0609 from the health inspection on February 13, 2025.

• Health citation

  CMS removed citation F0637 from the health inspection on February 13, 2025.

• Health citation

  CMS removed citation F0645 from the health inspection on February 13, 2025.

• Health citation

  CMS removed citation F0656 from the health inspection on February 13, 2025.

• Health citation

  CMS removed citation F0657 from the health inspection on February 13, 2025.

• Health citation

  CMS removed citation F0676 from the health inspection on February 13, 2025.

• Health citation

  CMS removed citation F0677 from the health inspection on February 13, 2025.

• Health citation

  CMS removed citation F0679 from the health inspection on February 13, 2025.

• Health citation

  CMS removed citation F0684 from the health inspection on February 13, 2025.

• Health citation

  CMS removed citation F0686 from the health inspection on February 13, 2025.

• Health citation

  CMS removed citation F0695 from the health inspection on February 13, 2025.

• Health citation

  CMS removed citation F0745 from the health inspection on February 13, 2025.

• Health citation

  CMS removed citation F0757 from the health inspection on February 13, 2025.

• Health citation

  CMS removed citation F0758 from the health inspection on February 13, 2025.

• Health citation

  CMS removed citation F0761 from the health inspection on February 13, 2025.

• Health citation

  CMS removed citation F0790 from the health inspection on February 13, 2025.

• Health citation

  CMS removed citation F0880 from the health inspection on February 13, 2025.

• Health citation

  CMS removed citation F0881 from the health inspection on February 13, 2025.

• Health citation

  CMS removed citation F0921 from the health inspection on February 13, 2025.

• Fire safety citation

  CMS removed citation E0007 from the fire safety inspection on February 13, 2025.

• Fire safety citation

  CMS removed citation K0225 from the fire safety inspection on February 13, 2025.

• Fire safety citation

  CMS removed citation K0321 from the fire safety inspection on February 13, 2025.

• Fire safety citation

  CMS removed citation K0324 from the fire safety inspection on February 13, 2025.

• Fire safety citation

  CMS removed citation K0353 from the fire safety inspection on February 13, 2025.

• Fire safety citation

  CMS removed citation K0355 from the fire safety inspection on February 13, 2025.

• Fire safety citation

  CMS removed citation K0362 from the fire safety inspection on February 13, 2025.

• Fire safety citation

  CMS removed citation K0372 from the fire safety inspection on February 13, 2025.

• Fire safety citation

  CMS removed citation K0521 from the fire safety inspection on February 13, 2025.

• Fire safety citation

  CMS removed citation K0920 from the fire safety inspection on February 13, 2025.

• Fire safety citation

  CMS removed citation K0930 from the fire safety inspection on February 13, 2025.

CMS stopped payment for new admissions from July 15, 2026, for 1 day.

See this home on CMS Care Compare

• Health citation

  CMS changed citation F0658 from severity D to E. It is from the health inspection on March 19, 2026. Severity E: potential for more than minimal harm, pattern.

CMS lists this as a standard inspection and a complaint inspection.

Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

47 of 337 Minnesota homes (14%) got a citation at the immediate jeopardy level in 2026.

• Citation F0880. Severity J: immediate jeopardy, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS has cited this home for F0880 5 times since 2024.

• Citation F0684. Severity G: actual harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS has cited this home for F0684 3 times since 2025.

• Citation F0680. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure the activities program is directed by a qualified professional.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS has cited this home for F0812 2 times since 2025.

• Citation F0944. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

  CMS has cited this home for F0944 2 times since 2025.

• Citation F0946. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide training in compliance and ethics.

  CMS has cited this home for F0946 2 times since 2025.

• Citation F0689. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS has cited this home for F0689 9 times since 2023.

• Citation F0921. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

  CMS has cited this home for F0921 4 times since 2024.

• Citation F0550. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS has cited this home for F0550 5 times since 2024.

• Citation F0558. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Reasonably accommodate the needs and preferences of each resident.

  CMS has cited this home for F0558 2 times since 2024.

• Citation F0605. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

  CMS has cited this home for F0605 2 times since 2025.

• Citation F0627. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

  CMS has cited this home for F0627 3 times since 2025.

• Citation F0628. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

  CMS has cited this home for F0628 4 times since 2025.

• Citation F0657. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS has cited this home for F0657 3 times since 2025.

• Citation F0676. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

  CMS has cited this home for F0676 2 times since 2025.

• Citation F0677. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS has cited this home for F0677 4 times since 2023.

• Citation F0679. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide activities to meet all resident's needs.

  CMS has cited this home for F0679 2 times since 2025.

• Citation F0685. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Assist a resident in gaining access to vision and hearing services.

  CMS has cited this home for F0685 2 times since 2024.

• Citation F0690. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

• Citation F0712. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that the resident and his/her doctor meet face-to-face at all required visits.

• Citation F0756. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

• Citation F0908. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Keep all essential equipment working safely.

• Citation F0917. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.

• Citation F0732. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Post nurse staffing information every day.

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CMS lists this as a standard inspection.

• Citation K0293. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have properly located and lighted "Exit" signs.

• Citation K0923. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have proper medical gas storage and administration areas.

  CMS has cited this home for K0923 2 times since 2025.

• Citation K0372. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  CMS has cited this home for K0372 2 times since 2025.

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• Health citation

  CMS removed citation F0580 from the health inspection on December 8, 2025.

CMS lists this as a complaint inspection.

• Citation F0604. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

  CMS lists it as corrected on May 6, 2026.

• Citation F0627. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

  CMS lists it as corrected on May 6, 2026.

• Citation F0628. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

  CMS lists it as corrected on May 6, 2026.

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• Health citation

  CMS changed citation F0880 from severity E to K. It is from the health inspection on December 8, 2025. Severity K: immediate jeopardy, pattern.

CMS lists this as a complaint inspection.

• Citation F0658. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on May 9, 2026.

See this home on CMS Care Compare

CMS lists this as a complaint inspection.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on March 31, 2026.

• Citation F0842. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  CMS lists it as corrected on March 31, 2026.

  CMS has cited this home for F0842 2 times since 2026.

See this home on CMS Care Compare

• Health citation

  CMS removed citation F0553 from the health inspection on August 30, 2024.

• Health citation

  CMS removed citation F0572 from the health inspection on August 30, 2024.

• Health citation

  CMS removed citation F0577 from the health inspection on August 30, 2024.

• Health citation

  CMS removed citation F0584 from the health inspection on August 30, 2024.

• Health citation

  CMS removed citation F0585 from the health inspection on August 30, 2024.

• Health citation

  CMS removed citation F0609 from the health inspection on August 30, 2024.

• Health citation

  CMS removed citation F0610 from the health inspection on August 30, 2024.

• Health citation

  CMS removed citation F0636 from the health inspection on August 30, 2024.

• Health citation

  CMS removed citation F0638 from the health inspection on August 30, 2024.

• Health citation

  CMS removed citation F0645 from the health inspection on August 30, 2024.

• Health citation

  CMS removed citation F0655 from the health inspection on August 30, 2024.

• Health citation

  CMS removed citation F0656 from the health inspection on August 30, 2024.

• Health citation

  CMS removed citation F0660 from the health inspection on August 30, 2024.

• Health citation

  CMS removed citation F0679 from the health inspection on August 30, 2024.

• Health citation

  CMS removed citation F0680 from the health inspection on August 30, 2024.

• Health citation

  CMS removed citation F0693 from the health inspection on August 30, 2024.

• Health citation

  CMS removed citation F0697 from the health inspection on August 30, 2024.

• Health citation

  CMS removed citation F0699 from the health inspection on August 30, 2024.

• Health citation

  CMS removed citation F0732 from the health inspection on August 30, 2024.

• Health citation

  CMS removed citation F0757 from the health inspection on August 30, 2024.

• Health citation

  CMS removed citation F0758 from the health inspection on August 30, 2024.

• Health citation

  CMS removed citation F0835 from the health inspection on August 30, 2024.

• Health citation

  CMS removed citation F0883 from the health inspection on August 30, 2024.

• Health citation

  CMS removed citation F0943 from the health inspection on August 30, 2024.

• Fire safety citation

  CMS removed citation E0004 from the fire safety inspection on August 30, 2024.

• Fire safety citation

  CMS removed citation E0007 from the fire safety inspection on August 30, 2024.

• Fire safety citation

  CMS removed citation E0022 from the fire safety inspection on August 30, 2024.

• Fire safety citation

  CMS removed citation E0025 from the fire safety inspection on August 30, 2024.

• Fire safety citation

  CMS removed citation E0026 from the fire safety inspection on August 30, 2024.

• Fire safety citation

  CMS removed citation E0034 from the fire safety inspection on August 30, 2024.

• Fire safety citation

  CMS removed citation E0036 from the fire safety inspection on August 30, 2024.

• Fire safety citation

  CMS removed citation E0037 from the fire safety inspection on August 30, 2024.

• Fire safety citation

  CMS removed citation E0039 from the fire safety inspection on August 30, 2024.

• Fire safety citation

  CMS removed citation K0211 from the fire safety inspection on August 30, 2024.

• Fire safety citation

  CMS removed citation K0225 from the fire safety inspection on August 30, 2024.

• Fire safety citation

  CMS removed citation K0291 from the fire safety inspection on August 30, 2024.

• Fire safety citation

  CMS removed citation K0321 from the fire safety inspection on August 30, 2024.

• Fire safety citation

  CMS removed citation K0324 from the fire safety inspection on August 30, 2024.

• Fire safety citation

  CMS removed citation K0345 from the fire safety inspection on August 30, 2024.

• Fire safety citation

  CMS removed citation K0346 from the fire safety inspection on August 30, 2024.

• Fire safety citation

  CMS removed citation K0353 from the fire safety inspection on August 30, 2024.

• Fire safety citation

  CMS removed citation K0354 from the fire safety inspection on August 30, 2024.

• Fire safety citation

  CMS removed citation K0355 from the fire safety inspection on August 30, 2024.

• Fire safety citation

  CMS removed citation K0363 from the fire safety inspection on August 30, 2024.

• Fire safety citation

  CMS removed citation K0372 from the fire safety inspection on August 30, 2024.

• Fire safety citation

  CMS removed citation K0374 from the fire safety inspection on August 30, 2024.

• Fire safety citation

  CMS removed citation K0521 from the fire safety inspection on August 30, 2024.

• Fire safety citation

  CMS removed citation K0711 from the fire safety inspection on August 30, 2024.

• Fire safety citation

  CMS removed citation K0761 from the fire safety inspection on August 30, 2024.

• Fire safety citation

  CMS removed citation K0901 from the fire safety inspection on August 30, 2024.

• Fire safety citation

  CMS removed citation K0914 from the fire safety inspection on August 30, 2024.

• Fire safety citation

  CMS removed citation K0920 from the fire safety inspection on August 30, 2024.

CMS lists this as a complaint inspection.

• Citation F0697. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe, appropriate pain management for a resident who requires such services.

  CMS lists it as corrected on February 13, 2026.

  CMS has cited this home for F0697 3 times since 2025.

See this home on CMS Care Compare

CMS lists this as a complaint inspection.

• Citation F0842. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  CMS lists it as corrected on February 13, 2026.

See this home on CMS Care Compare

CMS stopped payment for new admissions from January 10, 2026, for 41 days.

See this home on CMS Care Compare

CMS lists this as a standard inspection and a complaint inspection.

Severity K is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

74 of 337 Minnesota homes (22%) got a citation at the immediate jeopardy level in 2025.

• Citation F0689. Severity K: immediate jeopardy, pattern.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on January 22, 2026.

• Citation F0880. Severity K: immediate jeopardy, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on February 20, 2026.

• Citation F0578. Severity J: immediate jeopardy, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on January 22, 2026.

• Citation F0550. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on January 22, 2026.

• Citation F0576. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure residents have reasonable access to and privacy in their use of communication methods.

  CMS lists it as corrected on January 22, 2026.

  CMS has cited this home for F0576 2 times since 2025.

• Citation F0725. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  CMS lists it as corrected on January 22, 2026.

• Citation F0730. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Observe each nurse aide's job performance and give regular training.

  CMS lists it as corrected on January 22, 2026.

• Citation F0867. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  CMS lists it as corrected on January 22, 2026.

• Citation F0919. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Make sure that a working call system is available in each resident's bathroom and bathing area.

  CMS lists it as corrected on January 22, 2026.

  CMS has cited this home for F0919 2 times since 2024.

• Citation F0941. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

  CMS lists it as corrected on February 20, 2026.

• Citation F0942. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

  CMS lists it as corrected on January 22, 2026.

• Citation F0944. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

  CMS lists it as corrected on January 22, 2026.

• Citation F0946. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide training in compliance and ethics.

  CMS lists it as corrected on January 22, 2026.

• Citation F0949. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide behavior health training consistent with the requirements and as determined by a facility assessment.

  CMS lists it as corrected on January 22, 2026.

• Citation F0677. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on January 22, 2026.

• Citation F0804. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  CMS lists it as corrected on January 22, 2026.

  CMS has cited this home for F0804 5 times since 2024.

• Citation F0921. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

  CMS lists it as corrected on January 22, 2026.

• Citation F0628. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

  CMS lists it as corrected on January 22, 2026.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on January 22, 2026.

  CMS has cited this home for F0656 5 times since 2023.

• Citation F0657. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS lists it as corrected on January 22, 2026.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on January 22, 2026.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on February 20, 2026.

  CMS has cited this home for F0695 2 times since 2024.

• Citation F0697. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe, appropriate pain management for a resident who requires such services.

  CMS lists it as corrected on February 20, 2026.

• Citation F0726. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

  CMS lists it as corrected on February 20, 2026.

  CMS has cited this home for F0726 2 times since 2024.

• Citation F0740. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

  CMS lists it as corrected on January 22, 2026.

  CMS has cited this home for F0740 2 times since 2023.

• Citation F0757. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident’s drug regimen must be free from unnecessary drugs.

  CMS lists it as corrected on January 22, 2026.

  CMS has cited this home for F0757 2 times since 2025.

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CMS lists this as a standard inspection.

• Citation K0351. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Install an approved automatic sprinkler system.

  CMS lists it as corrected on January 26, 2026.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on January 26, 2026.

• Citation K0923. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have proper medical gas storage and administration areas.

  CMS lists it as corrected on January 26, 2026.

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• Fine

  CMS changed the fine from July 17, 2023 from $90,297 to $95,471.

• Fine

  CMS changed the fine from March 27, 2024 from $17,120 to $17,813.

• Health citation

  CMS removed citation F0758 from the health inspection on February 13, 2025.

CMS lists this as a standard inspection and a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

68 of 337 Minnesota homes (20%) got a citation at the actual harm level in 2025.

• Citation F0686. Severity G: actual harm, isolated.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on August 26, 2025.

  CMS has cited this home for F0686 2 times since 2024.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on August 26, 2025.

• Citation F0921. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

  CMS lists it as corrected on August 26, 2025.

• Citation F0925. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

  CMS lists it as corrected on August 26, 2025.

• Citation F0550. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on August 26, 2025.

• Citation F0804. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  CMS lists it as corrected on August 26, 2025.

• Citation F0805. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

  CMS lists it as corrected on September 11, 2025.

• Citation F0552. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that residents are fully informed and understand their health status, care and treatments.

  CMS lists it as corrected on August 26, 2025.

• Citation F0576. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure residents have reasonable access to and privacy in their use of communication methods.

  CMS lists it as corrected on August 26, 2025.

• Citation F0580. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  CMS lists it as corrected on August 26, 2025.

• Citation F0585. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on August 26, 2025.

• Citation F0605. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

  CMS lists it as corrected on August 26, 2025.

• Citation F0636. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

  CMS lists it as corrected on August 26, 2025.

• Citation F0638. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Assure that each resident’s assessment is updated at least once every 3 months.

  CMS lists it as corrected on August 26, 2025.

• Citation F0641. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident receives an accurate assessment.

  CMS lists it as corrected on August 26, 2025.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on August 26, 2025.

• Citation F0657. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS lists it as corrected on August 26, 2025.

• Citation F0676. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

  CMS lists it as corrected on August 26, 2025.

• Citation F0679. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide activities to meet all resident's needs.

  CMS lists it as corrected on August 26, 2025.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on August 26, 2025.

• Citation F0688. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

  CMS lists it as corrected on August 26, 2025.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on August 26, 2025.

• Citation F0692. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide enough food/fluids to maintain a resident's health.

  CMS lists it as corrected on August 26, 2025.

  CMS has cited this home for F0692 3 times since 2024.

• Citation F0697. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe, appropriate pain management for a resident who requires such services.

  CMS lists it as corrected on August 26, 2025.

• Citation F0699. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care or services that was trauma informed and/or culturally competent.

  CMS lists it as corrected on August 26, 2025.

• Citation F0755. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on August 26, 2025.

  CMS has cited this home for F0755 2 times since 2025.

• Citation F0757. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident’s drug regimen must be free from unnecessary drugs.

  CMS lists it as corrected on August 26, 2025.

• Citation F0760. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that residents are free from significant medication errors.

  CMS lists it as corrected on August 26, 2025.

  CMS has cited this home for F0760 2 times since 2025.

• Citation F0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on August 26, 2025.

• Citation F0806. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

  CMS lists it as corrected on August 26, 2025.

  CMS has cited this home for F0806 2 times since 2025.

• Citation F0808. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

  CMS lists it as corrected on August 26, 2025.

  CMS has cited this home for F0808 2 times since 2025.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on August 26, 2025.

• Citation F0577. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

  CMS lists it as corrected on August 26, 2025.

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CMS lists this as a standard inspection.

• Citation K0225. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have stairways and smokeproof enclosures used as exits that meet safety requirements.

  CMS lists it as corrected on August 26, 2025.

• Citation K0372. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  CMS lists it as corrected on August 26, 2025.

• Citation K0353. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on August 26, 2025.

• Citation K0355. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Properly select, install, inspect, or maintain portable fire extinguishes.

  CMS lists it as corrected on August 26, 2025.

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CMS lists this as a complaint inspection.

• Citation F0554. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Allow residents to self-administer drugs if determined clinically appropriate.

  CMS lists it as corrected on July 30, 2025.

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• Fine

  CMS changed the fine from August 6, 2024 from $16,055 to $16,349.

CMS lists this as a complaint inspection.

• Citation F0627. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

  CMS lists it as corrected on June 24, 2025.

• Citation F0628. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

  CMS lists it as corrected on June 24, 2025.

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• Fine

  CMS changed the fine from March 27, 2024 from $16,801 to $17,120.

CMS lists this as a complaint inspection.

• Citation F0755. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on April 21, 2025.

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CMS lists this as a complaint inspection.

• Citation F0700. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

  CMS lists it as corrected on March 27, 2025.

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• Fine

  CMS changed the fine from July 17, 2023 from $88,823 to $90,297.

• Fine

  CMS changed the fine from March 27, 2024 from $25,847 to $16,801.

CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

68 of 337 Minnesota homes (20%) got a citation at the actual harm level in 2025.

• Citation F0760. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that residents are free from significant medication errors.

  CMS lists it as corrected on March 31, 2025.

• Citation F0727. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

  CMS lists it as corrected on March 31, 2025.

• Citation F0804. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  CMS lists it as corrected on March 31, 2025.

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CMS lists this as a complaint inspection.

• Citation F0804. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  CMS lists it as corrected on February 28, 2025.

• Citation F0550. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on February 28, 2025.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on February 28, 2025.

• Citation F0692. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide enough food/fluids to maintain a resident's health.

  CMS lists it as corrected on February 28, 2025.

• Citation F0806. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

  CMS lists it as corrected on February 28, 2025.

• Citation F0808. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

  CMS lists it as corrected on February 28, 2025.

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CMS lists this as a complaint inspection.

Severity L is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

74 of 337 Minnesota homes (22%) got a citation at the immediate jeopardy level in 2025.

• Citation E0015. Severity L: immediate jeopardy, widespread.

  The rule CMS cited: Address subsistence needs for staff and patients.

  CMS lists it as corrected on February 28, 2025.

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CMS lists this as a complaint inspection.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on February 2, 2025.

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CMS lists this as a complaint inspection.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on January 6, 2025.

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• Staffing

  Total nurse staffing reported to CMS went from 3.7 to 3.2 hours per resident per day.

CMS stopped payment for new admissions from September 28, 2024, for 31 days.

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• Fine

  CMS changed the fine from July 7, 2022 from $251,337 to $256,533.

• Fine

  CMS changed the fine from January 22, 2024 from $14,678 to $14,813.

CMS lists this as a complaint inspection.

• Citation F0921. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

  CMS lists it as corrected on October 4, 2024.

• Citation F0689. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on October 29, 2024.

• Citation F0677. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on October 4, 2024.

• Citation F0685. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Assist a resident in gaining access to vision and hearing services.

  CMS lists it as corrected on October 4, 2024.

• Citation F0686. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on October 4, 2024.

• Citation F0791. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide or obtain dental services for each resident.

  CMS lists it as corrected on October 4, 2024.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on October 4, 2024.

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• Fine

  CMS changed the fine from March 18, 2022 from $20,636 to $21,100.

• Fine

  CMS changed the fine from January 8, 2024 from $4,893 to $4,938.

CMS lists this as a complaint inspection.

Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

54 of 337 Minnesota homes (16%) got a citation at the immediate jeopardy level in 2024.

• Citation F0689. Severity J: immediate jeopardy, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on August 22, 2024.

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CMS fine of $18,146 on August 6, 2024.

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• Star rating

  The CMS overall star rating changed from 1 of 5 to not rated by CMS.

• Star rating

  The CMS health inspection star rating changed from 1 of 5 to not rated by CMS.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to not rated by CMS. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to not rated by CMS.

• Special Focus Facility

  CMS now lists this home as a Special Focus Facility.

• Fine

  CMS changed the fine from July 7, 2022 from $243,255 to $251,337.

• Fine

  CMS changed the fine from July 17, 2023 from $80,250 to $88,823.

• Fine

  CMS changed the fine from December 11, 2023 from $11,538 to $11,645.

• Fine

  CMS changed the fine from March 18, 2022 from $19,400 to $20,636.

• Fine

  CMS changed the fine from November 6, 2023 from $8,391 to $8,468.

CMS stopped payment for new admissions from May 25, 2024, for 25 days.

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• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

CMS lists this as a complaint inspection.

Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

54 of 337 Minnesota homes (16%) got a citation at the immediate jeopardy level in 2024.

• Citation F0689. Severity J: immediate jeopardy, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on May 17, 2024.

• Citation F0610. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Respond appropriately to all alleged violations.

  CMS lists it as corrected on May 17, 2024.

  CMS has cited this home for F0610 2 times since 2023.

• Citation F0843. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.

  CMS lists it as corrected on May 17, 2024.

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CMS lists this as a complaint inspection.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on May 31, 2024.

  CMS has cited this home for F0609 2 times since 2023.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on May 31, 2024.

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CMS lists this as a complaint inspection.

• Citation F0726. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

  CMS lists it as corrected on May 31, 2024.

• Citation F0558. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Reasonably accommodate the needs and preferences of each resident.

  CMS lists it as corrected on May 31, 2024.

• Citation F0759. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure medication error rates are not 5 percent or greater.

  CMS lists it as corrected on May 31, 2024.

• Citation F0804. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  CMS lists it as corrected on May 31, 2024.

• Citation F0919. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Make sure that a working call system is available in each resident's bathroom and bathing area.

  CMS lists it as corrected on May 31, 2024.

• Citation F0550. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on May 31, 2024.

• Citation F0692. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide enough food/fluids to maintain a resident's health.

  CMS lists it as corrected on May 31, 2024.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on May 31, 2024.

• Citation F0803. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on June 19, 2024.

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CMS lists this as a complaint inspection.

• Citation E0037. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish staff and initial training requirements.

  CMS lists it as corrected on June 19, 2024.

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CMS fine of $17,813 on March 27, 2024.

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• Star rating

  The CMS staffing star rating changed from 4 of 5 to 3 of 5.

• Staffing

  Total nurse staffing reported to CMS went from 4.3 to 3.7 hours per resident per day.

CMS fine of $14,814 on January 22, 2024.

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CMS fine of $4,938 on January 8, 2024.

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CMS fine of $4,545 on January 2, 2024.

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CMS fine of $11,645 on December 11, 2023.

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CMS lists this as a complaint inspection.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on December 14, 2023.

• Citation F0610. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Respond appropriately to all alleged violations.

  CMS lists it as corrected on December 14, 2023.

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CMS lists this as a complaint inspection.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on December 15, 2023.

• Citation F0677. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on December 15, 2023.

• Citation F0926. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have policies on smoking.

  CMS lists it as corrected on December 15, 2023.

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CMS fine of $8,469 on November 6, 2023.

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CMS lists this as a complaint inspection.

Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

14 of 337 Minnesota homes (4%) got a citation at the immediate jeopardy level in 2023.

• Citation F0689. Severity J: immediate jeopardy, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on November 30, 2023.

• Citation F0838. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

  CMS lists it as corrected on November 30, 2023.

• Citation F0660. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Plan the resident's discharge to meet the resident's goals and needs.

  CMS lists it as corrected on November 30, 2023.

• Citation F0740. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

  CMS lists it as corrected on November 30, 2023.

• Citation F0742. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

  CMS lists it as corrected on November 30, 2023.

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