Cycle 1
Health 2025-02-12 · Fire 2025-02-12
21 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Bemidji, MN
Havenwood Care Center
1-star overall rating with 1-star inspections with $21,590 in total fines with 21 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
1633 Delton Avenue Nw, Bemidji, MN
(218) 444-1745
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
65
Certified beds
Average residents
60
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1986-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.73
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.62
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.01
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.39
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.53
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.80
CMS adjusted RN staffing hours
Adjusted total hours
4.41
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,213
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
58.77
Composite VBP score used to determine payment impact.
Payment multiplier
1.0140
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
9.38
Baseline 23.39% · Performance 17.08% · Measure score 9.38 · Achievement 9.38 · Improvement 9
Healthcare-associated infections
5.28
Baseline 8.92% · Performance 6.65% · Measure score 5.28 · Achievement 3.95 · Improvement 5.28
Total nurse turnover
4.46
Baseline 63.49% · Performance 45.45% · Measure score 4.46 · Achievement 4.46 · Improvement 4.17
Adjusted total nurse staffing
4.38
Baseline 3.86 hours · Performance 4.33 hours · Measure score 4.38 · Achievement 4.38 · Improvement 1.91
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.19% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 88 · Observed rate 12.5% · Lower 95% interval 7.65% |
| Discharge to community | 53.01% |
50.57%
2.4 pts better
|
No Different than the National Rate · Eligible stays 75 · Observed rate 46.67% · Lower 95% interval 42.79% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 91.67% |
95.27%
3.6 pts worse
|
Numerator 44 · Denominator 48 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 48 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 19 · Denominator 38 |
| Discharge mobility score | 52.63% |
50.94%
1.7 pts better
|
Numerator 20 · Denominator 38 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 48 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.65% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 4% · Lower 95% interval 3.94% |
| Staff COVID-19 vaccination coverage | 9.7% |
8.2%
1.5 pts better
|
Numerator 13 · Denominator 134 |
| Staff flu vaccination coverage | 22.35% |
42%
19.6 pts worse
|
Numerator 38 · Denominator 170 |
| Discharge function score | 55.26% |
56.45%
1.2 pts worse
|
Numerator 21 · Denominator 38 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 90% |
96.28%
6.3 pts worse
|
Numerator 18 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 33.33% |
25.2%
8.1 pts better
|
Numerator 8 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 4.0 |
1.7
2.3 pts worse
|
1.9
2.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.0 · Observed 2.6 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
2.0
0.7 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.1 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
97.3%
1.3 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.1% · Q3 98.1% · Q4 98.1% · 4Q avg 98.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.5% |
96.1%
0.4 pts better
|
95.5%
1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.9% |
3.9%
3 pts better
|
3.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.8% |
4.3%
1.5 pts better
|
11.4%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 2.0% · Q3 0.0% · Q4 2.6% · 4Q avg 2.8% |
| Percentage of long-stay residents who lose too much weight | 7.0% |
4.1%
2.9 pts worse
|
5.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 10.4% · Q3 6.0% · Q4 3.9% · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.8% |
12.4%
1.4 pts worse
|
19.6%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 18.0% · Q3 10.0% · Q4 13.5% · 4Q avg 13.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.1% |
17.5%
1.6 pts worse
|
16.7%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 17.9% · Q3 17.9% · Q4 17.5% · 4Q avg 19.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 19.4% |
22.5%
3.1 pts better
|
16.3%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.1% |
18.6%
2.5 pts better
|
14.9%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 13.0% · Q3 34.9% · Q4 13.5% · 4Q avg 16.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.0% |
2.3%
0.7 pts worse
|
1.0%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.0% · Q3 5.4% · Q4 3.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
2.6%
0.7 pts better
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.0% |
24.8%
8.8 pts better
|
19.8%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 12.3% · Q3 19.9% · Q4 18.1% · 4Q avg 16.0% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
5.4%
2.3 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 0.0% · Q3 0.0% · Q4 8.7% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.7% |
88.6%
3.1 pts better
|
81.7%
10 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.7% · Q2 93.9% · Q3 89.7% · Q4 88.1% · 4Q avg 91.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.3% |
14.0%
8.3 pts worse
|
12.0%
10.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.3% · Observed 19.6% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.8% |
82.7%
6.9 pts worse
|
79.7%
3.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.5% |
23.1%
3.6 pts better
|
23.9%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.5% · Observed 17.4% · Expected 21.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-05 · Fire 2024-04-05
15 health deficiencies
Top issue: Resident Rights (5 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-05-24 · Fire 2023-05-24
14 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-12
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2025-03-31
F · Potential for more than minimal harm
2025-02-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-31
F · Potential for more than minimal harm
2025-02-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-31
F · Potential for more than minimal harm
2025-02-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-03-31
E · Potential for more than minimal harm
2025-02-12
K163 · Construction Deficiencies
Fire Safety
Install noncombustible or limited-combustible interior walls.
Corrected 2025-03-31
E · Potential for more than minimal harm
2025-02-12
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-03-31
E · Potential for more than minimal harm
2025-02-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-31
E · Potential for more than minimal harm
2025-02-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-12
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-31
F · Potential for more than minimal harm
2024-04-05
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-05-10
F · Potential for more than minimal harm
2024-04-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-25
F · Potential for more than minimal harm
2024-04-05
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2024-05-09
F · Potential for more than minimal harm
2024-04-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-26
F · Potential for more than minimal harm
2024-04-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-03
F · Potential for more than minimal harm
2024-04-05
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2024-04-26
F · Potential for more than minimal harm
2024-04-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-04-05
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-05-08
D · Potential for more than minimal harm
2024-04-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-03
F · Potential for more than minimal harm
2023-05-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-29
F · Potential for more than minimal harm
2023-05-24
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-06-29
F · Potential for more than minimal harm
2023-05-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-30
F · Potential for more than minimal harm
2023-05-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-07-12
F · Potential for more than minimal harm
2023-05-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-30
F · Potential for more than minimal harm
2023-05-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-07-10
F · Potential for more than minimal harm
2023-05-24
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2023-06-28
F · Potential for more than minimal harm
2023-05-24
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-07-21
E · Potential for more than minimal harm
2023-05-24
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-24
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-07-07
E · Potential for more than minimal harm
2023-05-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-05-24
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-05-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-29
D · Potential for more than minimal harm
2023-05-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-07-05
C · Minimal harm
2023-05-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-29
Inspection history
Recent health citations
G · Actual harm
2026-01-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-02-23
D · Potential for more than minimal harm
2025-10-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-12-22
D · Potential for more than minimal harm
2025-10-22
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-12-22
J · Immediate jeopardy
2025-08-07
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-08-31
D · Potential for more than minimal harm
2025-07-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-06-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-14
E · Potential for more than minimal harm
2025-02-12
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-12
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-12
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-12
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-12
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-12
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-12
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-12
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-12
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-12
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-31
D · Potential for more than minimal harm
2024-06-04
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-06-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-05-09
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-06-15
F · Potential for more than minimal harm
2024-04-05
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-04-05
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-04-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-04-05
F729 · Nursing and Physician Services Deficiencies
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-05
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-05
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-05
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-05
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-05
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-05
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-05-10
J · Immediate jeopardy
2023-12-04
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-12-28
J · Immediate jeopardy
2023-10-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-09-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-18
F · Potential for more than minimal harm
2023-05-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-21
F · Potential for more than minimal harm
2023-05-24
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-05-24
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-05-24
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-05-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-07-17
D · Potential for more than minimal harm
2023-05-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-05-24
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-24
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-05-24
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-05-24
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-07-21
Penalties and ownership
What sits behind the stars
$13,397
2023-12-04
Fine
Fine · fine $13,397
Fine
$8,193
2023-09-21
Fine
Fine · fine $8,193
Fine
Ownership
Birchem, James
5% Or Greater Direct Ownership Interest · Individual
Birchem, Kathleen
5% Or Greater Direct Ownership Interest · Individual
Birchem, James
Corporate Director · Individual
Birchem, James
Corporate Officer · Individual
Birchem, Kathleen
Corporate Director · Individual
Birchem, Kathleen
Corporate Officer · Individual
Eldercare Of Minnesota, Inc
Operational/Managerial Control · Organization
Erickson, Laura
Operational/Managerial Control · Individual
Jarvis, Steffanie
Corporate Director · Individual
Wilcox, David
Operational/Managerial Control · Individual
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