Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Shakopee Friendship Manor during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and total-assist transfer needs fell from a mechanical lift when two NAs failed to fully secure the sling and did not double-check the attachment points before raising the resident. The resident was lifted with one sling loop not connected, the hanger shifted, and the resident fell to the floor, sustaining a head laceration, bruising, pain, and an acute shoulder fracture. One NA was under the age allowed to operate the lift in that manner, and both staff members acknowledged they were distracted and assumed the other had completed the attachment.
A resident with a history of colon cancer and recent bowel surgery was admitted after a fall. Staff failed to report and evaluate a distinctive foul odor in the resident's room, which was later associated with a large, bloody, black stool observed during hospital transfer. The odor, recognized by an EMT as indicative of a GI bleed, was not reported to nursing staff, resulting in a lack of timely assessment and physician notification. The facility's policy did not specifically address GI bleed symptoms, contributing to the delay in care.
Failure to complete, retain, and make readily available a PASARR Level II for a resident with paranoid schizophrenia and cognitive impairment. The resident’s record contained a PAS and diagnosis information, but lacked evidence the facility followed up to determine whether an OBRA Level II referral was needed. The DON stated the facility typically filed PAS paperwork received from the hospital and was not aware follow-up was required; a later OBRA Level I screening indicated a Level II referral was needed.
Failure to care plan wandering behaviors for a resident with severe cognitive impairment and Alzheimer’s disease. The resident was documented as wandering in halls, entering other residents’ rooms, and asking to leave, while risk assessments and staff interviews confirmed a history of wandering and that redirection and activities were helpful interventions. The care plan did not include behavioral interventions for the resident’s wandering.
A resident reported worsening hearing and was observed to be hard-of-hearing, frequently needing questions repeated and turning toward the left ear. Although nursing summaries showed changes from adequate hearing to moderate/minimal difficulty, the record lacked evidence that the change was fully evaluated or that any treatment, wax check, or audiology referral was completed. Staff acknowledged the hearing concern and that it had been noticed, but documentation of a comprehensive follow-up was absent.
A resident with moderate cognitive impairment had frequent moderate pain documented on the MDS, but the facility did not complete a comprehensive pain assessment when pain complaints continued. The resident reported ongoing knee and leg pain after a prior fall, said scheduled pain meds were not effective, and noted that knee patches helped somewhat. Although the MAR/TAR showed scheduled analgesics and one cold pack entry, repeated pain complaints were charted by NA staff without a detailed assessment of pain characteristics, triggers, relief measures, or pain-management goals, and the DON/ADON acknowledged the documentation lacked needed detail.
A resident with multiple medical conditions and care needs did not have a comprehensive care plan in place. The care plan lacked essential information on ADLs, cognitive concerns, and specific preferences, leading to inadequate guidance for staff. Interviews with staff confirmed the care plan's incompleteness, despite facility policies requiring individualized care plans.
A resident with a foley catheter was not provided with proper enhanced barrier precautions (EBP) as required. Despite EBP signage, the care plan and records lacked mention of the catheter and EBP. A nursing assistant was observed not wearing a PPE gown while providing catheter care, although gloves were worn. Interviews with staff confirmed the expectation to wear gowns and gloves, but the nursing assistant admitted to forgetting. The infection control preventionist noted the absence of EBP documentation in the resident's records.
The facility failed to ensure RN coverage for a minimum of eight consecutive hours daily, as required. This deficiency was identified through staffing data and schedules, revealing gaps in RN coverage on specific dates, including weekends and holidays. Interviews with staff confirmed the expectation of RN presence, but acknowledged challenges in maintaining coverage, particularly during call-ins. Despite efforts to improve staffing, the facility did not meet the requirement on several occasions.
Mechanical Lift Transfer Failure
Penalty
Summary
The facility failed to ensure a mechanical lift was used according to the manufacturer’s instructions and Federal requirements during a transfer of a resident who depended on staff for bed-to-chair transfers. Two nursing assistants attempted to move the resident from bed to wheelchair using an EZ Way Classic lift, but they did not fully secure the sling to the hanger bar before raising the resident. One lower sling attachment point on the left side was not connected, and neither staff member performed a final check of all four attachment points before the lift was moved away from the bed. The resident involved had severe cognitive impairment, Alzheimer’s disease, age-related physical debility, and required extensive assistance with transfers. During the transfer, the resident was raised while the sling was not fully attached, the hanger bar turned as the resident was lifted, and the resident fell out of the sling onto the floor. The resident sustained a head laceration, pain in the right arm and elbow, bruising, and an acute fracture of the surgical neck of the right shoulder. The resident’s family reported that video footage showed the staff did not secure the sling straps or double-check them before lifting the resident. The two nursing assistants involved acknowledged that they were distracted during the transfer and did not verify that the sling was properly attached. One nursing assistant stated they assumed the other had completed the attachment, and both confirmed that no one checked the loops before the resident was lifted. One of the nursing assistants was under the age permitted to operate the lift in the manner used during the transfer, and the facility’s own staff and leadership acknowledged that the sling was not secured and that the resident was not being watched closely during the lift.
Failure to Timely Evaluate and Act on Signs of GI Bleed
Penalty
Summary
A deficiency occurred when the facility failed to timely act upon or evaluate signs of a potential gastrointestinal (GI) bleed in a resident who was later hospitalized with GI complications. The resident, who had a history of colon cancer, chronic kidney disease, and a recent right hemicolectomy, was admitted to the facility following a fall and cervical fracture. Initial assessments and documentation did not indicate any active or monitored GI bleed, and bowel movements were recorded as formed and normal in consistency. However, on the day of the incident, a nursing assistant noticed a foul, unusual odor in the resident's room in the early morning, which was later identified as similar to the odor present when the resident had a large, bloody, black stool during transfer to the hospital. The nursing assistant did not report the abnormal odor to the nurse, assuming it had already been addressed based on information from a previous shift. Later that day, while preparing the resident for hospital transfer due to complaints of head and neck pain, staff observed a large amount of bloody, loose stool with a distinctive odor, which an EMT identified as indicative of a GI bleed. The nurse confirmed that if such an odor had been reported earlier, they would have initiated monitoring and notified the physician immediately. The medical record lacked evidence that the odor noticed by direct care staff was evaluated in a timely manner or that the resident was assessed for other symptoms of a GI bleed prior to the EMT's arrival. Interviews with the assistant director of nursing and director of nursing confirmed that no concerns about a potential GI bleed were reported by staff prior to the incident. The facility's change of condition policy required evaluation and physician notification for significant changes in status but did not specifically mention GI bleed symptoms such as abnormal stool odor or black stools. The failure to recognize and act upon early signs of a GI bleed resulted in a delay in care for the resident.
Failure to Complete and Retain PASARR Level II Documentation
Penalty
Summary
The facility failed to ensure a Level II PASARR was completed, retained in the medical record, and readily available for continuity of care for one resident. The resident’s significant change MDS indicated moderate cognitive impairment and no delusions, hallucinations, or behaviors. The resident’s clinical diagnosis report listed paranoid schizophrenia, cerebral infarction, muscle weakness, drug induced dyskinesia, diabetes, and hypertension. An attached fax from Senior LinkAge Line dated 4/5/23 showed a PAS stating the resident met Level of Care for MA payment and noted the PAS was not final until the lead agency sent documentation to the nursing facility. The resident’s medical record lacked evidence that the facility followed up with Senior LinkAge Line to determine whether further assessment was needed or to obtain documentation confirming whether an OBRA Level II screening was required. During interview, the administrator stated the facility usually filed PAS screenings received from the hospital and was not aware it needed to follow up to obtain a document stating whether a resident needed an OBRA Level II referral. The facility later provided an OBRA Level I Criteria Screening dated 1/11/23 that indicated the resident had cognitive or behavioral signs suggesting developmental disabilities or mental illness, had a diagnosis or symptoms of mental illness that significantly interfered with functioning, needed supportive services due to mental illness, and required an OBRA Level II referral.
Failure to Care Plan Wandering Behaviors
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with wandering behaviors. R9 had severe cognitive impairment, Alzheimer’s disease, and was dependent on staff for use of a manual wheelchair during the lookback period. Although the quarterly MDS indicated R9 had not wandered during the lookback period, multiple progress notes documented wandering and related behaviors, including trying to find the doctor’s office, wandering down halls, wheeling into other residents’ rooms, attempting to push a wheelchair in the hallway, yelling for a laundry staff member, restlessness, anxiety, and asking for help leaving. A wandering risk assessment identified R9 as disoriented, forgetful, with short attention span, independent with mobility using a mobility aide, taking antipsychotics and antidepressants, and at high risk for wandering. A later wandering risk scale documented R9 as low risk and noted no history of wandering, despite the documented wandering behaviors. The order summary report identified R9 as a wander risk and fall risk, with red and yellow squares placed on the outside of the door and frequent checks ordered. The follow-up question report documented additional wandering into hallways and unsafe areas and into other residents’ rooms. The care plan did not include behavioral interventions for wandering when these behaviors were observed. During interviews, staff stated R9 could wheel herself independently, had a history of wandering, and that redirection and giving her an activity had been helpful, while the ADON stated wandering should have been care planned as soon as the behaviors started and that wandering was part of R9’s baseline.
Failure to Evaluate Worsening Hearing
Penalty
Summary
The facility failed to ensure a change in hearing ability was acted upon, fully evaluated, and, if needed, treated or referred to audiology for one resident who complained of worsening hearing. The resident’s annual MDS identified severe cognitive impairment, no delusional thinking, and recorded hearing as adequate with no hearing aid use. During observation, the resident was seated in a recliner without hearing aids or audio devices and stated the hearing in the left ear had been getting worse, adding that she could not afford an audiologist. The resident was hard-of-hearing during the interview, frequently turned her head to the left, and repeatedly asked for questions to be repeated. She also stated she did not wear hearing aids and was unsure what, if anything, staff were doing about her hearing concerns. Review of nursing summaries showed changes in recorded hearing status over time, including adequate, moderate difficulty, adequate, and minimal difficulty, with no hearing devices used, but the medical record lacked evidence that these changes were comprehensively evaluated or that any intervention was pursued. Direct care staff stated the resident had been hard-of-hearing for a while and that staff often had to repeat themselves, while an LPN stated changes in hearing should be evaluated by visual inspection for wax and treatment if needed, with audiology referral arranged if necessary and documented in progress notes. The ADON confirmed the record showed hearing difficulty on some nursing summaries, acknowledged staff awareness of the issue, and stated audiology was not a prompted topic at care conferences. The facility did not provide a hearing evaluation and/or treatment policy when requested.
Incomplete Pain Assessment and Intervention Documentation
Penalty
Summary
The facility failed to ensure recorded complaints of pain or discomfort were comprehensively assessed and, if needed, that interventions were developed to provide adequate comfort for one resident with moderate cognitive impairment. The resident’s quarterly MDS documented frequent pain with moderate intensity, and the care plan identified pain medication use along with interventions such as rest, pain flow sheets, non-medication techniques, and review of medication efficacy. However, the resident’s pain assessment dated 5/11/25 did not include a comprehensive evaluation of the pain’s characteristics, history, factors that worsened or improved it, or the resident’s goals for pain management, and it did not identify changes to the pain control regimen. During observation and interview, the resident stated she had pain in her legs and knees from a prior fall and described the pain as sore and terrible. She reported that scheduled pain pills were being added but remained ineffective, and said ice or heat did not help. She also stated knee patches used during therapy helped somewhat and suggested they might help more if used more often. The resident’s record showed pain complaints documented by nursing assistants on multiple July dates, and a progress note recorded knee pain and short temper, but the chart lacked evidence of a comprehensive pain assessment tied to those complaints. The MAR showed scheduled pain medications including tramadol, Tylenol, and muscle rub cream, and the TAR showed only one documented non-pharmacological intervention, a cold pack, with no other recorded interventions despite repeated pain complaints. Staff interviews confirmed that pain was tracked through pain assessments, MAR/TAR pain levels, and that complaints should be evaluated, but the ADON and DON acknowledged the assessments needed more detail and that the record lacked a comprehensive pain evaluation. The facility’s pain policy required reassessment on admission, annually, quarterly, and with significant change in condition, and stated residents experiencing pain should be treated with non-pharmacological and pharmacological methods and re-evaluated for effectiveness.
Incomplete Care Plan for Resident
Penalty
Summary
The facility failed to develop and maintain a comprehensive care plan for a resident, identified as R29, which resulted in a deficiency in providing appropriate care. R29 was admitted with several medical conditions, including atrial fibrillation, mild cognitive impairment, muscle weakness, repeated falls, cardiomyopathy, chronic kidney disease, hypertension, and congestive heart failure. The Minimum Data Set (MDS) assessment indicated that R29 required maximum assistance for various activities of daily living (ADLs) and had specific care needs, such as assistance with toileting, dressing, and transfers. However, the care plan lacked evidence of addressing these needs, as well as cognitive concerns, behavioral symptoms, falls, pressure ulcers, communication, bowel and bladder management, dental care, skin integrity, medication needs, and pain management. Interviews with staff members, including nursing assistants and a registered nurse, revealed that the care plan did not provide sufficient guidance for R29's care. Nursing assistants relied on the Kardex, a shorter version of the care plan, which also lacked critical information about R29's care needs, such as transfer assistance, preference for female caregivers, and the requirement for two staff members to be present due to past accusations. The registered nurse confirmed that R29 had specific preferences and behaviors that were not adequately addressed in the care plan, and the MDS coordinator acknowledged that the care plan was incomplete, missing essential sections that should have been included. The facility's policy on care planning emphasized the importance of developing an individualized plan of care to address each resident's specific problems and needs. Despite this policy, the care plan for R29 was not comprehensive, as confirmed by the assistant director of nursing and the administrator. The deficiency in the care plan was identified during a survey, highlighting the facility's failure to ensure that R29 received appropriate and consistent care based on her needs and preferences.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and maintain enhanced barrier precautions (EBP) for a resident who was reviewed for transmission-based precautions. The resident, who had intact cognition and diagnoses of hemiplegia and rhabdomyolysis, was admitted with a foley catheter following a visit to the emergency room for urinary retention. Despite the presence of EBP signage outside the resident's room, the care plan, physician orders, and nursing assistant care sheet did not mention the foley catheter or EBP precautions. During an observation, a nursing assistant was seen rinsing a graduated cylinder used for catheter drainage without wearing the required personal protective equipment (PPE) gown, although gloves were worn. Interviews with various nursing staff, including nursing assistants and a licensed practical nurse, revealed that there was an understanding that PPE, including gowns and gloves, should be worn when providing hands-on care to residents with catheters. However, the nursing assistant admitted to forgetting to wear a gown while providing care. The infection control preventionist confirmed that the resident was placed under EBP upon returning from the emergency room and that the expectation was for staff to sanitize hands and wear gowns and gloves during care. It was also noted that the electronic medical record lacked documentation of EBP in the orders, care plan, and Kardex, which was acknowledged by the infection control preventionist and the assistant director of nursing.
Failure to Maintain 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 a day, as required. This deficiency was identified through a review of the Payroll Based Journal (PBJ) Staffing Data Report for the first quarter of 2024, which showed no RN hours on specific dates. Additionally, the facility's staffing schedules confirmed the absence of RN coverage on several occasions, including weekends and holidays. Interviews with the staffing coordinator, nursing assistants, and the assistant director of nursing (ADON) verified the expectation of having an RN on duty for eight consecutive hours each day, and acknowledged the failure to meet this requirement on the identified dates. The staffing coordinator mentioned that the facility had been working to improve RN coverage by hiring another RN in March and utilizing medical staffing agencies to fill open shifts. Despite these efforts, there were still instances where RN coverage was not maintained, particularly when there were call-ins. The administrator confirmed the absence of RN coverage on the specified dates and stated that the facility aimed to have an RN on duty for the required hours each day. A facility policy on staffing was requested during the investigation but was not provided.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 906 citations issued within 25 miles in the last 12 months — including the 25 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Shakopee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Gertrudes Health & Rehabilitation Center | 2.7 mi | ★★★★★ | 16 | 0 |
| Auburn Manor | 2.7 mi | ★★★★★ | 8 | 0 |
| Flagstone | 6.8 mi | ★★★★★ | 15 | 0 |
| The Estates At Excelsior Llc | 7.3 mi | ★★★★★ | 18 | 1 |
| Friendship Village Of Bloomington | 8.6 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Shakopee Friendship Manor.
100% money-back within 48 hours.
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.