Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hope Springs At Minnetonka during CMS and state inspections, most recent first.
The facility failed to submit accurate PBJ staffing data to CMS. Review of the PBJ report showed triggers for excessively low weekend staffing and lack of 24-hour licensed nursing coverage, but the facility schedule and nursing census sheets showed appropriate coverage was actually in place. The BK, who was responsible for PBJ reporting, said they did not have access to the schedule and used agency bills/payroll invoices instead, and the administrator confirmed reporting was based on invoices rather than the schedule.
The facility failed to ensure QAPI meetings were held quarterly. Requested meeting minutes were not fully provided, and the DON stated the January meeting was not held, a planned reschedule did not occur, and fall meeting notes could not be opened or were never resent. The QAPI Plan stated concerns, updates, or changes are to be reviewed at quarterly meetings.
Failure to obtain informed consent for psychotropic medications. A resident with severe cognitive impairment and diagnoses including Alzheimer’s disease, non-Alzheimer’s dementia, anxiety, and schizophrenia was prescribed Clozaril, Lexapro, lorazepam, and Olanzapine, but the record lacked evidence of consent with risk/benefit discussion for any of the medications. The DON stated the resident was not asked to sign because of cognitive concerns, despite the resident being their own decision maker and having windows of lucidity, and the decision was made without input from the resident or other IDT members.
Failure to Complete Ordered Swallowing Imaging: A resident with dysphagia, severe cognitive impairment, and multiple psychiatric and neurologic diagnoses was evaluated by SLP, who recommended instrumental swallow imaging to assess swallowing function and determine the safest, least restrictive diet. The SLP discharged services pending the imaging, with the DON agreeing to notify the provider and obtain the orders, but the resident’s chart showed no evidence the testing was ever completed and the DON confirmed the orders were missed and never passed on.
Failure to report a COVID-19 outbreak to MDH after an LPN and a resident tested positive for SARS-CoV-2. The infection control log showed the LPN was sent home and the resident was placed on precautions, but there was no evidence the outbreak was reported to state officials. The DON confirmed the outbreak was never reported because the reporting task had been handled by a retired staff member and was not reassigned.
The facility failed to provide a registered nurse (RN) for a minimum of eight consecutive hours per day, as required. This deficiency was identified through the PBJ Staffing Data Report, which showed gaps in RN coverage on multiple days. The Director of Nursing acknowledged the issue but highlighted the competence of the LPNs in maintaining continuity of care. A resident reported no concerns, and the facility's staffing policy was not provided.
The facility failed to ensure proper food storage and labeling, with items found unlabeled and undated. Staff did not consistently follow hygiene practices, such as wearing hair nets and performing hand hygiene between glove changes. Observations included condensation on stacked dishes and improper temperature checks of food items. The administrator confirmed expectations for these practices, which were not met by the staff.
The facility failed to maintain a comprehensive, data-driven QAPI program, affecting all 21 residents. The QA committee, including the DON, administrator, and medical director, met quarterly but lacked a system to collect and use data from all departments. No opportunities for improvement or performance projects were identified, and no meeting minutes or documentation were recorded, despite a policy emphasizing QAPI's importance.
The facility's QA committee, consisting of the DON, administrator, and medical director, failed to identify and implement performance improvement projects due to a lack of a system for data collection and utilization. Despite having a policy for conducting PIPs, the facility did not initiate any projects to address identified concerns, potentially affecting all 21 residents.
The facility's QA committee did not include the minimum required members, consisting only of the DON, administrator, and medical director. The DON confirmed the absence of at least two additional staff members, despite the facility's policy requiring broader representation, including key staff from other departments and potentially a resident and family members.
The facility failed to accurately code MDS assessments for medication use for several residents, misclassifying Melatonin as a hypnotic and omitting prescribed anticonvulsant and anticoagulant medications. The DON confirmed these inaccuracies, which were contrary to the RAI Manual guidelines.
Two residents in a facility were allowed to self-administer topical medications without proper assessments for safe use. One resident, despite being visually impaired, used a steroid cream unsupervised on areas not originally prescribed. Another resident self-administered multiple topical medications without a formal assessment. The facility's policy required assessments by an interdisciplinary team, but these were not conducted, leading to a deficiency.
A resident with intact cognition and mental health issues expressed a preference for vegetarian options, but the facility failed to consistently honor these preferences. Despite being aware of the resident's dietary likes and dislikes, the facility's staff did not document or provide meals that aligned with the resident's choices. The resident reported insufficient vegetarian options and received regular entrees if alternative options were not selected in time. Observations showed the resident was served unwanted meat, which was discarded without offering alternatives.
A resident's code status was inconsistently documented in their medical records, with discrepancies between their Health Care Directive and hospital orders. The facility failed to ensure provider involvement in the resident's DNR status, as required by policy.
The facility failed to follow a process for missing clothing, affecting three residents who reported missing items without receiving appropriate follow-up. Despite being informed, the facility's Missing Item Report lacked documentation of these concerns. The DON acknowledged the lack of follow-up and inadequate labeling of clothing, contributing to unresolved issues and dissatisfaction among residents and their families.
A facility failed to adequately monitor and assess skin alterations for a resident at risk of skin breakdown and did not effectively manage another resident's recurring UTIs, leading to hospitalizations. The facility did not adhere to care plans or conduct timely assessments, resulting in inadequate treatment of residents' health conditions.
A facility failed to assess a resident's safety for off-campus smoking and did not implement interventions for residents at risk of falls. One resident, who wished to smoke off-campus, was not provided with a safe smoking assessment or interventions. Another resident experienced multiple falls after ECT, but the facility did not update the care plan with new interventions. A third resident's care plan was not updated after a fall, lacking a root cause analysis and new interventions.
A resident experienced constant pain affecting daily activities, yet the facility failed to assess pain comprehensively or attempt non-pharmacological interventions. Despite receiving multiple pain medications, the care plan lacked specific non-pharmacological strategies, and no pain assessments were documented for seven months. Interviews revealed staff did not inquire about pain levels or implement non-pharmacological interventions unless ordered by a doctor. The facility's pain management policy was unavailable during the survey.
The facility failed to assess alternative interventions and obtain informed consent for bed assist devices for two residents. One resident's care plan and risk assessment indicated no need for bed rails, yet staff tied the call light to the siderail. Another resident's assessment showed bed rails were unnecessary, but the device remained in place without re-evaluation or consent. Staff interviews revealed a lack of clarity and communication regarding device assessments and use.
A resident with dysphagia and a history of coughing during meals did not consistently receive the prescribed mechanical soft diet. Despite orders for soft foods and ground meat, the resident often received meals not cut into bite-sized pieces, leading to multiple coughing episodes. Staff interviews revealed a lack of communication about the risks of the resident's food choices, and the DON had not discussed these risks with the resident.
The facility failed to deliver mail to residents on Saturdays and opened personal mail without proper authorization, affecting residents' privacy. Two residents reported their mail was opened despite requests for unopened delivery. The administrative assistant could not provide documentation of authorization for opening mail, leading to a deficiency.
The facility failed to schedule a registered nurse (RN) for a minimum of eight consecutive hours per day, as required. This deficiency was identified through a review of staffing data, which showed multiple dates without RN coverage. Interviews with staff confirmed gaps in coverage due to vacation time and limited RN staff. The facility preferred using licensed practical nurses (LPNs) familiar with residents over hiring agency RNs. The Facility Assessment Tool lacked identification of the need for eight consecutive hours of RN coverage daily.
The facility failed to properly store, label, and date food items, and did not ensure dishware was sanitized effectively, posing potential health risks. Observations revealed unlabeled and improperly stored food, as well as fluctuating dish machine temperatures that did not meet sanitization standards. The cook and administrator acknowledged these issues, which were not in compliance with the facility's policies.
The facility failed to submit accurate staffing data to CMS, with discrepancies noted between the PBJ Staffing Data Report and the facility's payroll sheets. The report indicated missing RN coverage and gaps in 24-hour licensed nursing coverage, which the payroll sheets contradicted. The administrator was unsure why the data was inaccurate, and no policy on PBJ data submission was provided.
The facility failed to implement a QAPI plan to maintain acceptable care levels and did not conduct ongoing quality assessment activities. Despite holding quarterly QAPI meetings, no performance improvement projects or formal documentation were developed to address repeated quality deficiencies. The focus had been on settling into a new building, with plans to address these issues in the future.
The facility's infection prevention and control program was found lacking in comprehensive policies and procedures, including those for TBP, EBP, and hand hygiene. The antibiotic stewardship protocol also lacked a system for monitoring antibiotic use. Interviews revealed informal monitoring practices without documentation, and the DON acknowledged the need for policy improvements.
The facility failed to ensure staff were educated on infection control standards, potentially affecting all 20 residents. An LPN was unsure about monitoring infections, and the DON acknowledged issues with providing education. The infection control policy lacked staff education requirements.
The facility failed to conduct regular resident council meetings due to the absence of the activity director, who was on medical leave. No one was assigned to organize the meetings during this period, affecting all 12 residents involved in the council. The facility's policy required monthly meetings, but this was not followed, leading to the deficiency.
The facility failed to provide residents with adequate access to their personal funds, limiting access to Wednesdays only, which affected their ability to manage financial affairs independently. Despite a policy allowing for emergency access, residents were not effectively informed or able to access funds on weekends or other days.
The facility failed to develop comprehensive care plans for two residents, lacking specific interventions for their identified needs. One resident's care plan missed goals for areas like pain management and ADLs, while another's lacked interventions for cognitive and behavioral concerns. Staff interviews revealed gaps in addressing chronic pain and anxiety, with the DON acknowledging the care plans were incomplete.
A resident with a right leg amputation was not provided with necessary assistance and coordination for their prosthetic care. Despite a provider's order to reassess the prosthesis due to skin irritation, the facility failed to contact the prosthetic company for six months. The resident expressed a desire to use the prosthesis, but it caused blisters, and staff were unaware of the need for a walking program. The care plan lacked details on prosthetic use, and no policy on prosthetic care was provided.
The facility did not act on pharmacist recommendations for two residents regarding unnecessary medications, including an opioid and liothyronine sodium. Additionally, the pharmacist failed to identify duplicative acetaminophen orders for a third resident. The DON was unaware of some recommendations, and the facility's process for communicating these to providers was inadequate.
A resident with schizoaffective disorder and chronic pain was prescribed multiple acetaminophen orders without clear administration parameters, leading to potential overuse. Facility staff, including an LPN and the DON, acknowledged the issue, noting that duplicate PRN orders for the same medication were not standard practice. The clinical pharmacist confirmed the oversight and the lack of guidance on safe dosage limits.
A facility failed to ensure a resident's dental status was accurately assessed and routine dental services were provided. The resident, who was cognitively intact and had multiple health issues, expressed a desire to see a dentist due to infrequent visits and dentures that occasionally fell out. Staff interviews revealed a lack of awareness and action regarding the resident's dental needs, with no specific policy on dental assessments in place.
The facility failed to offer influenza vaccinations to two residents, one with bipolar disorder and depression, and another with schizoaffective disorder and depression. The medical records lacked documentation of offers or declinations, and interviews revealed that the DON, responsible for vaccination oversight, may have overlooked obtaining necessary signatures. The facility's policy required consent but lacked a clear process for assessing vaccination status.
The facility did not ensure survey results were visible and accessible, as they were stored at the second-floor nurse's station, affecting all 20 residents and their visitors. During a resident council meeting, several residents expressed unawareness of the survey results' location. The administrative assistant confirmed the results should have been placed in a more accessible area.
Incorrect PBJ Staffing Data Reported to CMS
Penalty
Summary
The facility failed to submit accurate direct care staffing information to CMS based on payroll and other verifiable and auditable data for Quarter 1 2026. Review of the PBJ Report 1705D showed that the facility triggered metrics for excessively low weekend staffing and failure to have licensed nursing coverage for 24 hours a day on 10/1/25, 10/11/25, 11/28/25, 11/29/25, 12/28/25, and 12/29/25. However, review of the facility schedule and nursing staff census sheets showed the facility did have appropriate weekend coverage and 24-hour licensed coverage, indicating incorrect data had been reported to CMS. The bookkeeper stated they were responsible for PBJ reporting, did not have access to the schedule, and used agency staffing bills as the source for reporting data, which prevented them from determining when agency staff were actually scheduled or working. The administrator confirmed the bookkeeper did not have access to the facility schedule and based reporting on payroll invoices rather than the schedule. A policy for staff reporting was requested but not provided.
Failure to Hold Quarterly QAPI Meetings
Penalty
Summary
The facility failed to ensure that QAPI meetings were held on a quarterly basis. Record review and interview showed that the last three QAPI meeting minutes were requested by email, but only the April 6 meeting minutes were provided initially. The remaining two sets of minutes were requested again on multiple occasions, but were not provided. On interview, the DON stated the facility had not conducted its QAPI meeting in January, had planned to reschedule it, but was unable to do so. The DON also stated the facility had met in the fall, but the notes could not be opened, and despite being given the opportunity to resend them or provide them in another format, the document was never provided. The facility's QAPI Plan, last updated 6/19/2024, stated that QAPI concerns, updates, or changes are to be reviewed and discussed at quarterly meetings.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consents, including risk and benefit information, for psychotropic medications for one resident who was reviewed. The resident’s quarterly MDS indicated severe cognitive impairment and diagnoses of hyperlipidemia, Alzheimer’s disease, non-Alzheimer’s dementia, anxiety, and schizophrenia. The resident’s order summary showed prescriptions for Clozaril, Lexapro, lorazepam, and Olanzapine, but the medical record lacked evidence of informed consents for any of these medications. The DON stated they were responsible for completing psychotropic consents and did not have the resident sign because they believed the resident was unable to do so cognitively, even though the resident had windows of lucidity and confusion and was their own decision maker. The DON also stated they had been trying to obtain guardianship but had not been successful, and confirmed they made the decision not to have the resident sign without speaking to the resident or involving other interdisciplinary team members.
Failure to Complete Ordered Swallowing Imaging
Penalty
Summary
The facility failed to obtain diagnostic testing that had been recommended by SLP for a resident with dysphagia. The resident’s record showed severe cognitive impairment and diagnoses including HLD, Alzheimer’s disease, non-Alzheimer’s dementia, anxiety, and schizophrenia. The SLP initial evaluation documented that the resident needed instrumental swallow imaging to address decreased aspiration and choking risk and improve quality of life, and the discharge report stated that a modified barium swallow study or flexible endoscopic evaluation of swallow was recommended to assess impaired structures or musculature and determine the safest, least restrictive diet. The discharge report also stated that the DON and SLP agreed to discharge speech orders pending the swallowing imaging, with new orders to be obtained if the assessment indicated further dysphagia intervention was needed. However, the resident’s chart had no evidence that the diagnostic testing was ever completed. The SLP stated they informed the DON that imaging was needed and expected the DON to notify the provider and obtain the orders, but never heard back and did not follow up further unless additional evaluations were ordered. The DON confirmed responsibility for updating the provider and ensuring the testing was completed, but stated the orders were missed, never passed on, and speech was never continued as ordered.
Failure to Report COVID-19 Outbreak
Penalty
Summary
The facility failed to report a COVID-19 outbreak to MDH within one working day after a staff member and a resident tested positive for SARS-CoV-2. The Quarterly infection control log indicated that an LPN tested positive for COVID-19 and was sent home, and that resident R7 tested positive for COVID-19 and was placed on precautions. Although the facility had evidence that the staff member was removed from work and the resident was placed on precautions, no evidence was provided that the outbreak was reported to state officials as required. The DON confirmed that the facility had a COVID-19 outbreak involving one staff member and one resident and stated that it was never reported to MDH because the reporting task had previously been handled by a recently retired staff member and had not been reassigned.
Deficiency in RN Staffing Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was scheduled for a minimum of eight consecutive hours per day, which is a requirement for staffing in long-term care facilities. This deficiency was identified through the Payroll Based Journal (PBJ) Staffing Data Report, which indicated that there was no continuous 8-hour RN coverage for several days within the 4th quarter. Specific dates of non-compliance included multiple days in July, September, November, December, and January. During interviews, the Director of Nursing (DON) acknowledged the lack of continuous RN coverage but emphasized that the facility was staffed with competent licensed practical nurses (LPNs) who provided continuity of care. Despite the deficiency, a resident reported no concerns during a resident council meeting, and the facility's policy on staffing was requested but not received.
Deficiencies in Food Storage, Labeling, and Hygiene Practices
Penalty
Summary
The facility failed to ensure proper food storage and labeling practices, as observed during a kitchen tour. Sliced cheese and a half of Smithfield boneless ham were found without opened dates, and several items in the freezer, including bratwurst, tortillas, and a cheese omelet, were unlabeled and undated. Additionally, clean cups and bowls were stacked with condensation between them, indicating they were not completely dry before storage. Dietary aid (DA)-A confirmed these observations and admitted uncertainty about the duration of storage for some items. In terms of personal hygiene and food handling, DA-A was observed not wearing a hair net and failed to perform hand hygiene between glove changes while preparing and serving food. DA-A also did not check the temperature of all food items, such as the beef and pizza cooked in the microwave, relying instead on package instructions and personal judgment. DA-A acknowledged not washing hands between glove changes unless visibly dirty, citing time management as a reason. Another dietary aid, DA-B, was observed wearing a stocking cap without a beard net, despite having a longer loose hair on their chin. DA-B stated they took food temperatures and labeled food when opened, but their understanding of beard net requirements was incorrect. The facility administrator confirmed expectations for food temperature checks, proper labeling, and hand hygiene practices, which were not consistently followed by the staff. Facility policies required food to be labeled and dated, dishes to be air-dried, and staff to wear appropriate hair coverings and perform hand hygiene between tasks.
Lack of Comprehensive QAPI Program and Documentation
Penalty
Summary
The facility failed to maintain documentation and demonstrate evidence of a comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program, potentially affecting all 21 residents. During an interview, the Director of Nursing (DON) revealed that the Quality Assurance (QA) committee, which included the DON, the administrator, and the medical director, met quarterly to review adverse events. However, the committee lacked a system to identify, collect, and utilize data from all departments and had not identified any opportunities for improvement or performance improvement projects to implement. Additionally, the facility did not record any meeting minutes or documentation of their ongoing QA meetings, despite having a policy that outlined the importance of QAPI as a comprehensive approach to ensuring high-quality care.
Failure to Implement Effective Quality Assurance Measures
Penalty
Summary
The facility failed to ensure that its Quality Assurance (QA) committee effectively identified and implemented performance improvement projects to address identified concerns. During an interview, the Director of Nursing (DON) revealed that the QA committee, which included herself, the administrator, and the medical director, met quarterly to review adverse events. However, the committee lacked a system to identify, collect, and utilize data from all departments, and had not identified any opportunities for improvement or initiated any performance improvement projects. The facility's policy on Quality Assurance and Performance Improvement (QAPI) outlined that a Performance Improvement Project (PIP) should be a concentrated effort on a specific problem within the facility, involving data collection and intervention for improvements. Despite this policy, the facility had not conducted any PIPs to examine and improve care or services in areas needing attention. This deficiency had the potential to affect all 21 residents residing within the facility.
QA Committee Lacks Required Members
Penalty
Summary
The facility failed to ensure that the Quality Assurance (QA) committee included the minimum required members, which had the potential to affect all 21 residents residing within the facility. During an interview, the Director of Nursing (DON) confirmed that the committee, which consisted of herself (also serving as the infection preventionist), the administrator, and the medical director, met quarterly to review adverse events. However, the DON acknowledged that the QA committee did not include at least two additional staff members as required. The facility's policy on Quality Assurance and Performance Improvement (QAPI) indicated that the team should include the Administrator, DON, medical director, other key staff members from various departments, a designated resident if they wish to participate, and family or guardians if they wish to participate. Despite this policy, the committee had not yet included additional staff members, although there was a discussion about having a nursing assistant join the committee.
Inaccurate MDS Coding for Medication Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments were accurately coded to reflect the correct medication use for five residents. The inaccuracies involved misclassification of medications, such as coding Melatonin, a dietary supplement, as a hypnotic medication, contrary to the guidelines in the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual. Additionally, the MDS assessments for several residents did not accurately reflect the use of prescribed anticonvulsant and anticoagulant medications. For instance, one resident was recorded as taking a hypnotic medication without a prescription for such, and another resident's MDS did not mention the use of prescribed anticonvulsant and anticoagulant medications. The Director of Nursing (DON), who was responsible for completing the MDS, confirmed the inaccuracies during interviews. The DON acknowledged that medications should be coded based on their pharmacological classification rather than their intended use, as per the RAI Manual. Despite this, the DON incorrectly classified Melatonin as a hypnotic. The facility's MDS policy indicated that staff chart in the electronic medical record on various aspects of resident care, with a licensed practical nurse assisting the DON in interviewing residents and completing assessments. However, the deficiencies in the MDS coding were evident across multiple residents, indicating a systemic issue in accurately reflecting medication use.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents who self-administered topical medications were assessed for safe and appropriate use. Resident R11, who was cognitively intact, had an order for Betamethasone Valerate External Cream for a rash, which she self-administered unsupervised. However, there was no evidence in her electronic medical record (EMR) that she had been assessed for safe self-administration of the medication. Despite being visually impaired, R11 continued to self-administer the cream without staff assistance or assessment, and she used it on a different area of her body than originally prescribed. Resident R15, also cognitively intact, had multiple topical medications for self-administration, including hydrocortisone cream, antifungal powder, and Voltaren Gel. Similar to R11, R15's EMR lacked evidence of an assessment for safe self-administration of these medications. R15 self-applied the creams and powders as needed, and although staff were aware of the medications, there was no formal assessment conducted to ensure safe use. The facility's policy required an interdisciplinary team to assess residents' cognitive, physical, and visual abilities to self-administer medications. However, both R11 and R15 were not assessed according to this policy, leading to a deficiency in ensuring safe self-administration of medications. The Director of Nursing confirmed the lack of assessments for both residents, acknowledging the need for proper evaluation beyond just having a doctor's order.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor a resident's food preferences, which is a violation of the resident's right to self-determination. The resident, who had intact cognition and a history of mental health issues, expressed a preference for vegetarian options and a dislike for certain meats. Despite this, the facility did not consistently provide meals that aligned with the resident's preferences. The resident reported that the facility lacked sufficient vegetarian options and that they received the regular entree if they did not sign up for an alternative option in time. Observations and interviews revealed that the facility's dietary staff and nursing assistants were aware of the resident's food preferences but did not consistently document or honor them. The dietary aid and nursing assistant noted that the resident sometimes requested no meat and other times ate meat, but the kitchen's whiteboard and dietary book did not reflect any special instructions for the resident. During a meal observation, the resident was served barbequed pork, which they did not eat, and the meat was discarded without checking if the resident wanted anything else. The facility's policy required the cook and dietician to assess and document residents' food preferences, but this was not effectively implemented for the resident in question. The director of nursing acknowledged the resident's inconsistent preferences and the importance of providing food they liked, but the facility's practices did not ensure the resident's dietary needs and preferences were consistently met. This deficiency highlights a failure in the facility's processes to support resident choice and self-determination regarding food preferences.
Inconsistent Code Status Documentation for Resident
Penalty
Summary
The facility failed to ensure that a resident's code status was updated, consistent, and accurate throughout their medical record. The resident, who had intact cognition and diagnoses including orthostatic hypotension, dementia, and schizophrenia, had a Health Care Directive indicating they did not want CPR and preferred a natural death. However, the resident's Transfer and Discharge Orders from Regions Hospital indicated a full code status, creating a discrepancy in their medical records. Additionally, the resident's care plan lacked documentation of their code status, and their orders did not indicate their code status. Interviews with facility staff revealed that code statuses were reviewed at care conferences and during admission, but there was no provider order or involvement in the resident's DNR status. The Director of Nursing confirmed the absence of a provider's signature on the resident's Health Care Directive and Admission Record. The facility's policies required staff to assist residents in completing a POLST form and to ensure provider involvement, but these procedures were not followed for the resident in question.
Failure to Address Missing Clothing Concerns
Penalty
Summary
The facility failed to ensure a process for missing clothing was followed and residents received appropriate follow-up after reporting concerns of missing clothing. Three residents, identified as R1, R5, and R9, reported missing clothing items, but their concerns were not adequately addressed. R1, who was cognitively intact, reported a missing blue hoody and stated that missing clothing was a common occurrence. Despite informing the nursing assistants, R1 did not receive any follow-up. Similarly, R5, also cognitively intact, reported missing jeans, socks, and underwear, and although the director of nursing (DON) was informed, no follow-up was conducted. The facility's Missing Item Report lacked evidence of these reports, indicating a failure in the documentation process. R9, who had moderately impaired cognition and a history of paranoia, reported a missing expensive jacket. Despite the facility's process for handling missing items, R9's missing jacket was not documented in the missing items log. Interviews with staff revealed inconsistencies in the process of reporting and searching for missing items. NA-A and RN-A were unaware of R9's missing jacket, and the DON acknowledged that the facility did not find the jacket, leading to dissatisfaction from R9's family. The facility's labeling process for clothing was also inadequate, as the use of a sharpie that washed off after a few washes contributed to the issue of missing clothing. The facility's policy related to resident missing items was requested but not available at the time of the survey, further highlighting the lack of a structured process for addressing missing personal property. The DON admitted that the facility lacked follow-up on the missing items report and with missing items in general. The absence of a clear and effective procedure for managing and documenting missing clothing items resulted in unresolved concerns for the residents involved, impacting their right to a safe, clean, comfortable, and homelike environment.
Deficiencies in Skin and UTI Management
Penalty
Summary
The facility failed to adequately assess and monitor skin alterations for a resident, R8, who was at risk for skin breakdown due to various health conditions and the use of compression stockings. Despite having a care plan in place to prevent skin breakdown, the facility did not conduct regular skin assessments as required. R8 had a sore in the buttock area that was not properly documented or monitored, and staff failed to follow the facility's policy on skin monitoring, which required weekly assessments by a registered nurse and documentation of any skin alterations. Additionally, the facility did not effectively manage another resident, R3, who experienced multiple urinary tract infections (UTIs) leading to hospitalizations. R3, who was cognitively intact and mostly independent, reported symptoms of UTIs multiple times over several months. However, the facility did not conduct timely assessments or interventions, such as bladder scanning or proactive UTI assessments, to address these symptoms. The facility also failed to follow up with urology as previously recommended, and R3's care plan lacked updated interventions despite recurring UTIs. The facility's inaction in both cases highlights a lack of adherence to established care plans and policies, resulting in inadequate monitoring and treatment of residents' health conditions. The deficiencies in care for R3 and R8 were identified through observations, interviews, and document reviews, revealing significant gaps in the facility's processes for managing skin integrity and urinary health.
Failure to Assess Smoking and Fall Risks
Penalty
Summary
The facility failed to ensure a resident who wished to smoke off facility grounds was properly assessed for safety. The resident, who was cognitively intact and used a walker, expressed a desire to smoke off-campus. Despite being informed that the facility was non-smoking, the resident was not provided with a safe smoking assessment or any interventions to ensure her safety while smoking off-campus. The facility's staff, including the DON and RN, acknowledged the resident's desire to smoke but did not complete a safe smoking assessment or implement any safety measures. The facility also failed to adequately assess and implement new interventions for residents at risk of falls. One resident, with moderate cognitive impairment and a history of falls, experienced multiple falls, particularly after receiving ECT. Despite the pattern of falls occurring on Thursdays following ECT, the facility did not update the resident's care plan with new interventions or conduct a root cause analysis. The resident's care plan and Kardex lacked updated interventions, and orthostatic blood pressure monitoring was not conducted as required. Another resident, who had intact cognition and a history of falls, experienced a fall while trying to pick up a blanket from the floor. The facility's fall care plan for this resident was not updated following the incident, and there was no evidence of a root cause analysis or new fall prevention interventions. The DON confirmed that the resident's care plan was not updated after the fall, and the facility's fall book had not been fully implemented to analyze resident falls and create effective interventions.
Deficiency in Comprehensive Pain Management for Resident
Penalty
Summary
The facility failed to comprehensively assess and manage pain for a resident, identified as R11, who was receiving multiple medications for pain management. R11's quarterly Minimum Data Set (MDS) indicated that the resident was cognitively intact and experienced almost constant pain, which frequently affected sleep and daily activities. Despite receiving several medications for pain, including Ajovy, alpha-lipoic acid, Gabapentin, diclofenac sodium gel, Humira, and Nurtec, there were no documented non-pharmacological pain interventions attempted. The care plan for R11 lacked specific non-pharmacological pain interventions, and the electronic medical record (EMR) did not include any pain assessments over the past seven months, such as pain goals or what alleviated or exacerbated the pain. Interviews with R11 and facility staff revealed further deficiencies in pain management practices. R11 reported experiencing constant pain and expressed a desire to avoid additional medication, noting that staff did not attempt non-pharmacological interventions or inquire about pain levels. Licensed Practical Nurse (LPN)-A acknowledged that pain assessments should occur at least quarterly and whenever pain medication is administered, but noted that non-pharmacological interventions were not implemented unless ordered by a doctor. Nursing Assistant (NA)-C was unaware of any non-pharmacological interventions for R11 and had not attempted any herself. The Director of Nursing (DON) confirmed the absence of non-pharmacological interventions and noted that pain assessments were not conducted when R11 self-administered diclofenac sodium gel. Additionally, the facility's pain management policy was requested but unavailable during the survey.
Failure to Assess and Obtain Consent for Bed Assist Devices
Penalty
Summary
The facility failed to ensure that alternative interventions were assessed or attempted before using bed assist devices for two residents. For one resident, identified as R9, the facility did not document any assessment or education regarding the risks and benefits of bed assist devices, nor did they obtain informed consent. Despite the resident's care plan and risk assessment indicating that bed rails were not needed, staff tied the resident's call light to the bed siderail on multiple occasions. During an interview, the resident stated they did not use the device and were not informed about it upon admission. For another resident, identified as R14, the facility did not re-evaluate the need for a bed assist device after an assessment indicated it was no longer necessary. Initially, the resident's assessment suggested that bed rails were beneficial, but a later assessment showed they were not needed. Despite this, the bed assist device remained in place, and the resident did not recall being educated about its risks and benefits or providing consent. Staff continued to secure the call light to the siderail, and the resident stated they did not use the device. Interviews with facility staff, including nursing assistants and the director of nursing, revealed a lack of clarity and communication regarding the assessment and use of bed assist devices. The director of nursing acknowledged that assessments were supposed to be conducted upon admission and quarterly, but there was no evidence of follow-up or removal of devices when no longer needed. The facility's policy required informed consent and education about the risks and benefits of bed rails, which was not adhered to in these cases.
Failure to Provide Appropriate Modified Diet for Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that a resident with dysphagia and a history of coughing during meals received the appropriate modified diet. The resident, who was cognitively intact, had been admitted with diagnoses including dysphagia and moderate protein-calorie malnutrition. Despite orders for a mechanical soft texture diet, the resident often requested not to have their meat ground, and the facility did not consistently provide food in the prescribed form. The resident's care plan and Kardex indicated the need for soft foods and ground meat, but the resident sometimes received meals that were not cut into bite-sized pieces, leading to multiple coughing episodes during meals. Interviews and observations revealed that the staff did not consistently follow the dietary instructions, and there was a lack of communication regarding the risks and benefits of the resident's food choices. The resident reported not having discussions with staff about the risks of aspiration or choking. The Director of Nursing acknowledged the resident's refusal of the prescribed diet but had not discussed the associated risks with the resident. The facility's policy on modified diets was requested but not provided, indicating a potential gap in policy adherence or availability.
Failure to Ensure Privacy and Timely Delivery of Resident Mail
Penalty
Summary
The facility failed to ensure that residents had reasonable access to and privacy in their use of communication methods, specifically regarding the delivery and handling of personal mail. Observations and interviews revealed that the facility did not deliver mail to residents on Saturdays because the front office was locked and weekend staff did not have access. Additionally, the facility was opening residents' mail to process medical and financial items before delivering it to them, which was against the wishes of some residents. Two residents, R5 and R6, reported that their mail was being opened by the facility despite their requests for it to be delivered unopened. The administrative assistant explained that residents or their representatives were asked to sign a form authorizing the facility to open and manage business mail. However, there was no documentation to show that R5 had signed such an authorization, and R6's request to receive unopened mail had not been addressed. The facility's policy indicated that business mail was handled by the business office unless otherwise communicated, but the lack of proper documentation and failure to respect residents' requests led to the deficiency.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was scheduled for a minimum of eight consecutive hours per day, as required. This deficiency was identified through a review of the facility's Payroll Based Journal (PBJ) Staffing Data Report, which showed multiple dates between October 1, 2023, and December 23, 2023, where RN coverage was not provided. Interviews with facility staff, including the Director of Nursing (DON) and the administrator, confirmed the gaps in RN coverage. The DON attributed these gaps to vacation time and a limited number of RNs on staff, preferring to use licensed practical nurses (LPNs) who were familiar with the residents over hiring agency RNs. The facility's Staffing Contingency Plan and Facility Assessment Tool were reviewed, revealing that the facility had a plan to ask staff to pick up shifts in the event of a staffing shortage. However, the Facility Assessment Tool did not specify the need for eight consecutive hours of RN coverage daily. Interviews with the administrative assistant and the administrator indicated awareness of staffing requirements, but the administrator was unaware of the extent of the RN coverage gaps. The facility had the option to use agency nurses to fill RN hours but chose to rely on their own LPN staff, who were considered more knowledgeable about the residents.
Deficiencies in Food Storage and Dishware Sanitization
Penalty
Summary
The facility failed to ensure proper storage, labeling, and dating of food items in the kitchen, which could potentially affect all residents and staff consuming meals from the main kitchen. During an initial kitchen observation, it was noted that several refrigerated, frozen, and dry food items were not labeled with opened dates or identifying information. For instance, opened milk containers, slices of meat, and packages of roast beef lacked opened dates. Additionally, frozen items such as spring rolls and brats were found with freezer burn and without proper labeling. The facility's cook acknowledged these issues, stating that some items were not labeled due to rapid usage, while others were improperly stored or labeled. The facility also failed to maintain proper dishware sanitation practices, increasing the risk of foodborne illness. Observations revealed that the dish machine's temperature fluctuated and did not consistently reach the required levels for effective sanitization. The cook admitted to using a manual sanitization process with a bucket and test strips, but the test strips did not indicate appropriate sanitization levels when diluted in the sink. The administrator confirmed that the dish machine was a chemical sanitizer and that test strips were used to test the pH level of the standing water, but there was no alternative method to verify the dish machine's temperature. The facility's policies on food storage and dish machine sanitization were not adhered to, as evidenced by the improper storage of food items and the inadequate sanitization process. The administrator acknowledged that opened items should be dated and labeled, and food should not be stored on the floor. The dish machine was expected to operate at specific temperatures, but the observed practices did not align with these requirements, leading to potential health risks for residents and staff.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the first quarter of the year. The Payroll-Based Journal (PBJ) Staffing Data Report indicated that the facility lacked Registered Nurse (RN) coverage on multiple specified dates and did not maintain 24-hour licensed nursing coverage on certain days. Additionally, the report flagged the facility for low weekend staffing. However, a review of the facility's payroll sheets contradicted these findings, showing RN coverage on several of the dates in question and no gaps in 24-hour licensed nursing coverage. During an interview, the facility administrator stated that the PBJ data was submitted by the business office and was unsure why it did not accurately reflect staffing hours. The facility did not provide a policy regarding the submission of PBJ data to CMS when requested.
Failure to Implement QAPI Plan and Address Quality Deficiencies
Penalty
Summary
The facility failed to implement a Quality Assurance and Performance Improvement (QAPI) plan to ensure care and services were maintained at acceptable levels and continually improved. The facility did not conduct ongoing quality assessment and assurance activities, nor did it develop and implement appropriate plans of action to correct repeated quality deficiencies. These deficiencies were identified during the survey and were issues the facility was aware of or should have been aware of, potentially affecting all 20 residents residing in the facility. The facility's QAPI meeting minutes, attendance records, and evidence of ongoing performance improvement projects (PIPs) were requested but not provided. During an interview, the administrator stated that the facility held quarterly QAPI meetings but had not developed any PIPs or formal documentation to address previous and repeated quality deficiencies. The focus over the past year had been on settling into a new building, and plans to start addressing these issues were mentioned for the future. The QAPI plan dated 11/10/23 indicated intentions to establish a committee, conduct a facility assessment, identify areas of concern, and begin working on a PIP.
Inadequate Infection Control Program and Antibiotic Stewardship
Penalty
Summary
The facility failed to develop a comprehensive infection prevention and control program, which included written standards, policies, and procedures for reporting communicable diseases or infections, implementing transmission-based precautions (TBP) and enhanced barrier precautions (EBP), and ensuring proper hand hygiene practices. The existing policies lacked specific guidance on when and how to implement TBP, the required personal protective equipment (PPE) for different types of precautions, and staff education requirements. Additionally, there was no process for monitoring infection control practices among staff, and the antibiotic stewardship protocol did not include a system to monitor antibiotic use or assess residents' responses to antibiotics. Interviews with staff revealed that there was no specific method for monitoring residents with infections or those on antibiotics. The Director of Nursing (DON), who also served as the infection preventionist, acknowledged the deficiencies in the infection control policies and the lack of a structured monitoring process. The DON admitted that infection control practices were informally observed through cameras and personal observation without documentation. The antibiotic stewardship program was also found lacking in specific monitoring and data collection, with no structured discussion on antibiotic use in the quality committee. The DON, who had multiple responsibilities, recognized the need for improvement in the infection control policies.
Inadequate Staff Education on Infection Control
Penalty
Summary
The facility failed to ensure that staff were adequately educated on the standards, policies, and procedures of their infection control program, potentially impacting all 20 residents. During an interview, an LPN stated that they would alert the DON and the provider if a resident showed signs of infection, but there was no specific protocol for monitoring infections or antibiotic use. The LPN mentioned a recent in-service on enhanced barrier precautions but was unsure about education on policies and procedures. The DON confirmed that on-the-spot training was conducted when infection control concerns arose and acknowledged issues with providing education through an online platform. The facility's infection control policy, revised in June 2023, lacked direction on staff education requirements.
Failure to Conduct Regular Resident Council Meetings
Penalty
Summary
The facility failed to assist the resident council in setting up regular meetings, which affected all 12 residents who participated in the council. The deficiency was identified through interviews and document reviews, revealing that the resident council meetings were not held consistently. The activity director, who was responsible for organizing these meetings, was on medical leave from November 2023 to March 2024, and no one else was assigned to arrange the meetings during this period. As a result, the meetings were not conducted monthly as required by the facility's policy. During a resident council meeting with the surveyor, the residents confirmed that the meetings were not held consistently and expressed their desire for regular monthly meetings even during the activity director's absence. The facility's policy, updated in January 2023, stated that meetings should occur on the third Wednesday of each month, with the activity director or a designee responsible for facilitating them. However, this policy was not adhered to during the activity director's leave, leading to the deficiency.
Facility Fails to Provide Adequate Access to Resident Personal Funds
Penalty
Summary
The facility failed to ensure that residents had adequate access to their personal funds, which were deposited with the facility. This deficiency affected three residents who reported that they could only access their funds on Wednesdays, designated as 'money pass day.' The residents expressed that they were unable to access their funds on weekends or other days of the week, which limited their ability to manage their financial affairs independently. Interviews with the residents confirmed that they were informed by the facility staff that Wednesday was the only day they could access their funds. The facility's policy on resident personal accounts, dated July 2021, stated that while residents were encouraged to manage their money independently, access to funds was typically limited to Wednesday afternoons. The policy also mentioned that money pass was not available on weekends or holidays, although a small amount of cash was kept at the nursing station for emergencies. However, the administrative assistant clarified that residents were made aware of the designated money pass day, and it was implied that access could be granted on other days, including weekends, although this was not effectively communicated or implemented.
Incomplete Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, R11 and R19, which did not include resident-specific interventions for their identified needs. R11's care plan lacked desired goals and person-centered interventions for several areas, including visual function, communication, indwelling catheter, activities, dehydration/fluid maintenance, pressure ulcer/injury, and pain. Additionally, the care plan did not address R11's constipation diagnosis or provide instructions for activities of daily living (ADL) such as bathing, bed mobility, dressing, eating, oral care, personal hygiene, toilet use, or transfers. Interviews with staff revealed that R11 experienced chronic pain and anxiety, but non-pharmacological interventions were not offered, and the care plan was not updated to reflect these needs. Similarly, R19's care plan was incomplete, lacking person-centered interventions for identified concerns such as cognitive loss/dementia, behavioral symptoms, nutritional status, pressure ulcer/injury, and psychotropic drug use. The care plan only included a focus on COVID-19 and nutrition, failing to address other significant areas of concern. The Director of Nursing acknowledged responsibility for creating and updating care plans and admitted that the care plans for R11 and R19 were incomplete and not up to the desired standard. The facility's policy emphasized the need for comprehensive, resident-centered care plans that address all identified concerns and are updated as needed.
Failure to Coordinate Prosthetic Care for Resident
Penalty
Summary
The facility failed to provide necessary assistance and coordination of services for a resident with a prosthesis, leading to a deficiency in care. The resident, who was cognitively intact and had a right lower leg amputation, was supposed to use a prosthetic leg for mobility. However, due to complaints of itchy skin and irritation, the resident had not been using the prosthesis. Despite a provider's order to follow up with the prosthetic company for reassessment, the facility did not contact the company for six months after the resident's admission. The resident expressed a desire to use the prosthesis again, but it caused blisters, indicating a need for refitting. Observations and interviews revealed that the resident's prosthetic leg was not being used and was left standing in their room. Nursing staff, including a nursing assistant and a registered nurse, were unaware of the resident's prosthetic leg and the need for a walking program. The director of nursing acknowledged the need to contact the prosthetic company but admitted that no action had been taken. The resident's care plan lacked information on the fitting or use of the prosthesis, and a policy on prostheses and coordination of care was requested but not provided.
Failure to Act on Pharmacist Recommendations and Identify Medication Duplications
Penalty
Summary
The facility failed to act upon the consultant pharmacist's recommendations for two residents regarding unnecessary medications. One resident, who was cognitively intact and had a history of chronic pain and mental health disorders, was prescribed hydromorphone, an opioid pain medication, which they had not taken since December of the previous year. Despite the consultant pharmacist's recommendation to discontinue the medication in January, the order remained active, and the facility did not address the recommendation in a timely manner. The Director of Nursing (DON) was unaware of the recommendation until it was brought to their attention during the survey. Another resident, also cognitively intact, was prescribed liothyronine sodium for major depressive disorder. The consultant pharmacist questioned the continued need for this medication in March, but the recommendation was not communicated to the resident's provider. The DON confirmed that the pharmacy recommendations were kept in a folder in their office, which was not always accessible to providers, leading to a delay in addressing the pharmacist's concerns. Additionally, the consultant pharmacist failed to identify duplicative medication orders for a third resident, who had multiple orders for acetaminophen with no parameters for administration. The resident was using all prescribed orders, and the consultant pharmacist did not note any irregularities in their reviews. The DON acknowledged the oversight and expected the pharmacist to identify such issues during the monthly medication review.
Failure to Prevent Duplicative Medication Orders
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically duplicative prescriptions of acetaminophen. The resident, who was cognitively intact and diagnosed with schizoaffective disorder and chronic pain, had multiple orders for acetaminophen: 325 mg and 650 mg as needed (PRN), and 1000 mg three times a day for chronic pain. These orders lacked parameters for administration, leading to the potential for excessive acetaminophen intake. The medication administration record indicated that the resident had been using all prescribed Tylenol orders concurrently. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed that the presence of two PRN orders for the same medication was not standard practice and could result in excessive dosing. The DON expected nursing staff to identify and clarify duplicate orders with the provider, and the clinical pharmacist (CP) to note such issues during monthly medication reviews. However, the CP acknowledged that the duplicate orders were easy to overlook due to different naming conventions and confirmed the absence of guidance on safe dosage limits. The facility did not provide a policy related to medication reconciliation and unnecessary medications when requested.
Failure to Provide Routine Dental Care and Assessments
Penalty
Summary
The facility failed to ensure that a resident's dental status was accurately assessed and that routine dental services were provided. The resident, who was cognitively intact and had multiple diagnoses including renal insufficiency, diabetes mellitus, hemiplegia, and hemiparesis, was independent with oral hygiene but had no natural teeth. The resident's Minimum Data Set (MDS) did not indicate any issues with dentures, yet the resident expressed a desire to see a dentist, stating that it had been a long time since their last visit and that their dentures occasionally fell out. Despite this, the resident's dental care area assessment was triggered but not provided, and their care plan did not mention dentures. Interviews with staff revealed a lack of awareness and action regarding the resident's dental needs. A nursing assistant was unaware of any concerns with the resident's dentures, and a licensed practical nurse admitted to not conducting many oral assessments unless a resident complained of a sore. The administrative assistant acknowledged the resident's request for a dental appointment but found no record of a dental visit in the resident's chart. The Director of Nursing stated that dental services were offered as needed and encouraged regular dental visits, but there was no specific policy on dental assessments. The facility's policy on physician visits indicated that other provider services could be scheduled as needed, but there was no documentation of a dental assessment policy.
Failure to Offer Influenza Vaccinations
Penalty
Summary
The facility failed to ensure that influenza immunizations were offered to two residents, R20 and R11, as part of their immunization protocol. R20, who was cognitively intact and had diagnoses of bipolar disorder and depression, was not offered the influenza vaccine for the 2023-2024 season, as indicated by both the Minimum Data Set (MDS) and the Minnesota Immunization Information Connection Report. R20's medical record did not show any evidence of the vaccine being offered, received, or declined, and a request for R20's declination was not fulfilled. Similarly, R11, who was also cognitively intact with diagnoses of schizoaffective disorder and depression, was noted in the MDS to have been offered and refused the vaccine, but the medical record lacked documentation of this offer or declination. Interviews with facility staff revealed gaps in the vaccination process. An LPN stated that floor nurses did not determine vaccination needs, which was the responsibility of the Director of Nursing (DON), who also served as the infection preventionist. The DON explained that vaccines were provided either by the facility or through clinic providers, who would check vaccination status and make recommendations. However, the DON admitted to possibly overlooking obtaining declination signatures for residents who refused the vaccine, including R11, and acknowledged that R20's admission during a busy period might have led to the oversight. The facility's policy on vaccinations required education and consent before administration but lacked a clear process for assessing vaccination status, contributing to the deficiency.
Survey Results Not Accessible to Residents and Visitors
Penalty
Summary
The facility failed to ensure that survey results were posted in a location visible and easily accessible to residents and visitors. On May 15, 2024, the survey results were observed at the second-floor nurse's station, stored in a folder among several binders on the counter, making them not visible or accessible to residents or visitors. This deficiency had the potential to affect all 20 residents residing in the facility and their visitors, as they were unable to view the survey results without assistance. During a resident council meeting on the same day, several residents expressed that they were unaware of the location of the survey results and were interested in reading them. The administrative assistant, responsible for posting the survey results, acknowledged that the binder should have been placed in a more accessible location, such as the designated public viewing area on the first floor across from the business office. The administrator was not available for an interview regarding this issue.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Minnetonka
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Estates At Excelsior Llc | 3.2 mi | ★★★★★ | 18 | 1 |
| Folkestone | 3.7 mi | ★★★★★ | 3 | 0 |
| Augustana Chapel View Care Center | 4.5 mi | ★★★★★ | 6 | 0 |
| Hopkins Restorative Care Center | 4.6 mi | ★★★★★ | 23 | 0 |
| Sholom Home West | 5.3 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.