Minnesota ›Crystal

The Terrace at Crystal LLC

3245 Vera Cruz Avenue North, Crystal, MN 55422 · Hennepin County · 85 certified beds · avg 68 residents/day · certified since Nov 1, 1984

SFF

—/5
Health inspection rating (on-site)
12
Serious findings on record
$80,370
Fines, last 3 years
4.79
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: —/5 · CMS overall rating: —/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, one-off · Jun 5, 2026 · F-0880

The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.

Why it matters: Weak infection control lets illnesses like flu, COVID-19, and drug-resistant infections spread quickly among vulnerable residents.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

▲ Immediate jeopardy, repeated · Dec 8, 2025 · F-0689

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.

Corrected: Jan 22, 2026 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, repeated · Dec 8, 2025 · F-0880

The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.

Why it matters: Weak infection control lets illnesses like flu, COVID-19, and drug-resistant infections spread quickly among vulnerable residents.

Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.

Corrected: Feb 20, 2026 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · Dec 8, 2025 · F-0578

The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.

Why it matters: Ignoring these rights means residents may receive treatments they refused, or miss having their end-of-life wishes respected.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Jan 22, 2026 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · Aug 6, 2024 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Aug 22, 2024 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · Apr 12, 2024 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: May 17, 2024 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · Oct 31, 2023 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Nov 30, 2023 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · Aug 17, 2023 · F-0578 · triggered by a complaint

The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.

Why it matters: Ignoring these rights means residents may receive treatments they refused, or miss having their end-of-life wishes respected.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Aug 18, 2023 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Jun 5, 2026 · F-0684

The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.

Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

▲ Actual harm, one-off · Jul 2, 2025 · F-0686 · triggered by a complaint

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Aug 26, 2025 (Deficient, Provider has date of correction)

All citations in the current public record (153)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
Jun 5, 2026▲ J · Immediate jeopardy, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jun 5, 2026▲ G · Actual harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Jun 5, 2026F · Potential for harm, facility-wideThe facility's activities program was not run by a qualified professional. The person directing recreation and social activities must have proper training or credentials.
Jun 5, 2026F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jun 5, 2026F · Potential for harm, facility-wideThe facility did not give all staff the required training on its quality improvement program — the internal system for finding problems and making care better.
Jun 5, 2026F · Potential for harm, facility-wideThe facility did not provide its staff with training in compliance and ethics — teaching employees the laws and ethical standards that govern how residents must be treated.
Jun 5, 2026E · Potential for harm, repeatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jun 5, 2026E · Potential for harm, repeatedThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint
Jun 5, 2026D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Jun 5, 2026D · Potential for harm, one-offThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Jun 5, 2026D · Potential for harm, one-offThe facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function.
Jun 5, 2026D · Potential for harm, one-offThe facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely.
Jun 5, 2026D · Potential for harm, one-offThe facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay).
Jun 5, 2026D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Jun 5, 2026D · Potential for harm, one-offThe facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have.
Jun 5, 2026D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Jun 5, 2026D · Potential for harm, one-offThe facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle.
Jun 5, 2026D · Potential for harm, one-offThe facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids.
Jun 5, 2026D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Jun 5, 2026D · Potential for harm, one-offThe facility did not make sure residents actually saw their doctor face-to-face at all required visits. Doctors must examine nursing home residents in person on a regular schedule.
Jun 5, 2026D · Potential for harm, one-offThe facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Jun 5, 2026D · Potential for harm, one-offThe facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. · from a complaint
Jun 5, 2026D · Potential for harm, one-offThe facility did not provide bedrooms with required basics: a window to the outside, a room at or above ground level, adequate bedding, furniture that fits the resident's needs, or enough closet space.
Jun 5, 2026C · Minimal risk, facility-wideThe facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · from a complaint
Apr 16, 2026D · Potential for harm, one-offThe facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint
Apr 16, 2026D · Potential for harm, one-offThe facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely. · from a complaint
Apr 16, 2026D · Potential for harm, one-offThe facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · from a complaint
Mar 19, 2026E · Potential for harm, repeatedThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Mar 5, 2026D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Mar 5, 2026D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Jan 30, 2026D · Potential for harm, one-offThe facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint
Jan 21, 2026D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Dec 8, 2025▲ K · Immediate jeopardy, repeatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Dec 8, 2025▲ K · Immediate jeopardy, repeatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Dec 8, 2025▲ J · Immediate jeopardy, one-offThe facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Dec 8, 2025F · Potential for harm, facility-wideThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Dec 8, 2025F · Potential for harm, facility-wideThe facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately.
Dec 8, 2025F · Potential for harm, facility-wideThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint
Dec 8, 2025F · Potential for harm, facility-wideThe facility did not observe each nurse aide's job performance or provide regular training as required. · from a complaint
Dec 8, 2025F · Potential for harm, facility-wideThe facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them.
Dec 8, 2025F · Potential for harm, facility-wideThe facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area.
Dec 8, 2025F · Potential for harm, facility-wideThe facility did not develop or maintain an effective training program for its direct care staff, including training on how to communicate effectively with residents.
Dec 8, 2025F · Potential for harm, facility-wideThe facility did not educate its staff on residents' rights and the facility's responsibilities toward residents. Staff can only respect rights they've been taught about.
Dec 8, 2025F · Potential for harm, facility-wideThe facility did not give all staff the required training on its quality improvement program — the internal system for finding problems and making care better.
Dec 8, 2025F · Potential for harm, facility-wideThe facility did not provide its staff with training in compliance and ethics — teaching employees the laws and ethical standards that govern how residents must be treated.
Dec 8, 2025F · Potential for harm, facility-wideThe facility did not provide its staff with required training on behavioral health — caring for residents with conditions like dementia, depression, or other mental health needs.
Dec 8, 2025E · Potential for harm, repeatedThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Dec 8, 2025E · Potential for harm, repeatedThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint
Dec 8, 2025E · Potential for harm, repeatedThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Dec 8, 2025D · Potential for harm, one-offThe facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay).
Dec 8, 2025D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Dec 8, 2025D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Dec 8, 2025D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Dec 8, 2025D · Potential for harm, one-offThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Dec 8, 2025D · Potential for harm, one-offThe facility did not provide safe and appropriate pain management for a resident who needed it.
Dec 8, 2025D · Potential for harm, one-offThe facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Dec 8, 2025D · Potential for harm, one-offThe facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety.
Dec 8, 2025D · Potential for harm, one-offThe facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Jul 2, 2025▲ G · Actual harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Jul 2, 2025F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jul 2, 2025F · Potential for harm, facility-wideThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint
Jul 2, 2025F · Potential for harm, facility-wideThe facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint
Jul 2, 2025E · Potential for harm, repeatedThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Jul 2, 2025E · Potential for harm, repeatedThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint
Jul 2, 2025E · Potential for harm, repeatedThe facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems.
Jul 2, 2025D · Potential for harm, one-offThe facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand.
Jul 2, 2025D · Potential for harm, one-offThe facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately.
Jul 2, 2025D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Jul 2, 2025D · Potential for harm, one-offThe facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly.
Jul 2, 2025D · Potential for harm, one-offThe facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function.
Jul 2, 2025D · Potential for harm, one-offThe facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that.
Jul 2, 2025D · Potential for harm, one-offThe facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition.
Jul 2, 2025D · Potential for harm, one-offThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Jul 2, 2025D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Jul 2, 2025D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Jul 2, 2025D · Potential for harm, one-offThe facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have.
Jul 2, 2025D · Potential for harm, one-offThe facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle.
Jul 2, 2025D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Jul 2, 2025D · Potential for harm, one-offThe facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Jul 2, 2025D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Jul 2, 2025D · Potential for harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Jul 2, 2025D · Potential for harm, one-offThe facility did not provide safe and appropriate pain management for a resident who needed it.
Jul 2, 2025D · Potential for harm, one-offThe facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from.
Jul 2, 2025D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Jul 2, 2025D · Potential for harm, one-offThe facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Jul 2, 2025D · Potential for harm, one-offThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Jul 2, 2025D · Potential for harm, one-offThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint
Jul 2, 2025D · Potential for harm, one-offThe facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives.
Jul 2, 2025D · Potential for harm, one-offThe facility did not make sure special medical diets — like low-sodium or diabetic diets — were properly ordered by the resident's doctor or managed by a qualified dietitian as state law allows.
Jul 2, 2025D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jul 2, 2025C · Minimal risk, facility-wideThe facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman.
Jun 27, 2025D · Potential for harm, one-offThe facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. · from a complaint
May 21, 2025D · Potential for harm, one-offThe facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely. · from a complaint
May 21, 2025D · Potential for harm, one-offThe facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · from a complaint
Mar 27, 2025E · Potential for harm, repeatedThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Mar 10, 2025D · Potential for harm, one-offThe facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. · from a complaint
Feb 13, 2025▲ G · Actual harm, one-offThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Feb 13, 2025F · Potential for harm, facility-wideThe facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · from a complaint
Feb 13, 2025E · Potential for harm, repeatedThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint
Jan 17, 2025E · Potential for harm, repeatedThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint
Jan 17, 2025D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Jan 17, 2025D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Jan 17, 2025D · Potential for harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint
Jan 17, 2025D · Potential for harm, one-offThe facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · from a complaint
Jan 17, 2025D · Potential for harm, one-offThe facility did not make sure special medical diets — like low-sodium or diabetic diets — were properly ordered by the resident's doctor or managed by a qualified dietitian as state law allows. · from a complaint
Dec 24, 2024D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Dec 6, 2024D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Aug 30, 2024F · Potential for harm, facility-wideThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint
Aug 30, 2024E · Potential for harm, repeatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Aug 30, 2024D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Aug 30, 2024D · Potential for harm, one-offThe facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. · from a complaint
Aug 30, 2024D · Potential for harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Aug 30, 2024D · Potential for harm, one-offThe facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. · from a complaint
Aug 30, 2024D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Aug 6, 2024▲ J · Immediate jeopardy, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Apr 12, 2024▲ J · Immediate jeopardy, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Apr 12, 2024D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Apr 12, 2024C · Minimal risk, facility-wideThe facility did not have an agreement with at least one Medicare- or Medicaid-certified hospital to ensure residents can be transferred quickly when they need hospital care. · from a complaint
Apr 4, 2024D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Apr 4, 2024D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Mar 27, 2024F · Potential for harm, facility-wideThe facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint
Mar 27, 2024E · Potential for harm, repeatedThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint
Mar 27, 2024E · Potential for harm, repeatedThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · from a complaint
Mar 27, 2024E · Potential for harm, repeatedThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint
Mar 27, 2024E · Potential for harm, repeatedThe facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint
Mar 27, 2024D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Mar 27, 2024D · Potential for harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint
Mar 27, 2024D · Potential for harm, one-offThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint
Mar 27, 2024D · Potential for harm, one-offThe facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. · from a complaint
Dec 8, 2023D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Dec 8, 2023D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Nov 28, 2023D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Nov 28, 2023D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Nov 28, 2023D · Potential for harm, one-offThe facility did not have policies on smoking. · from a complaint
Oct 31, 2023▲ J · Immediate jeopardy, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Oct 31, 2023E · Potential for harm, repeatedThe facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. · from a complaint
Oct 31, 2023D · Potential for harm, one-offThe facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving. · from a complaint
Oct 31, 2023D · Potential for harm, one-offThe facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint
Oct 31, 2023D · Potential for harm, one-offThe facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD). · from a complaint
Sep 21, 2023▲ G · Actual harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Sep 21, 2023F · Potential for harm, facility-wideThe facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint
Sep 21, 2023E · Potential for harm, repeatedThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint
Sep 8, 2023F · Potential for harm, facility-wideThe facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint
Sep 8, 2023E · Potential for harm, repeatedThe facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. · from a complaint
Sep 8, 2023E · Potential for harm, repeatedWhen a resident had a planned discharge, the facility did not make sure the necessary information was communicated to the resident and to the doctors or facility taking over their care. · from a complaint
Sep 8, 2023E · Potential for harm, repeatedThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint
Sep 8, 2023D · Potential for harm, one-offThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Aug 24, 2023D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Aug 24, 2023D · Potential for harm, one-offThe facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint
Aug 24, 2023D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Aug 17, 2023▲ J · Immediate jeopardy, one-offThe facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. · from a complaint
Aug 11, 2023D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Aug 11, 2023D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (26 → 24).

YearCitationsSerious (G–L)Worst severity that year
2023243J ▲
2024242J ▲
2025735K ▲
2026322J ▲

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

7 fines totaling $80,370, plus 3 Medicare payment denial periods.

DateTypeAmount / length
Dec 8, 2025Payment Denial41 days from Jan 10, 2026
Aug 30, 2024Payment Denial31 days from Sep 28, 2024
Aug 6, 2024Fine$18,146
Mar 27, 2024Fine$17,813
Mar 27, 2024Payment Denial25 days from May 25, 2024
Jan 22, 2024Fine$14,814
Jan 8, 2024Fine$4,938
Jan 2, 2024Fine$4,545
Dec 11, 2023Fine$11,645
Nov 6, 2023Fine$8,469

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityMinnesota avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)4.794.833.95top 48% in Minnesota; top 17% in the U.S.
Registered Nurse hours0.571.220.69bottom 3% in Minnesota; bottom 48% in the U.S.
Weekend total nurse staffing4.384.273.50top 43% in Minnesota; top 14% in the U.S.
Weekend RN hours (not acuity-adjusted)0.460.690.48bottom 30% in Minnesota; top 38% in the U.S.
Total nursing staff turnover (%)34.742.245.8top 34% in Minnesota; top 23% in the U.S.
RN turnover (%)57.138.642.9bottom 20% in Minnesota; bottom 26% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.78, RN 0.57, weekend 4.36. Staffing rating: —/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: —/5 · long-stay residents: —/5 · short-stay residents: —/5

Who owns this facility

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
Katz, GeorgeIndividual5% or Greater Direct Ownership Interest100%01/01/2021
Katz, GeorgeIndividualCorporate OfficerNOT APPLICABLE01/01/2001
Merchant, ZenaeIndividualW-2 Managing EmployeeNOT APPLICABLE01/01/2021

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

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Facility data as of CMS processing date 2026-08-01. CCN 245289.