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Inspection findings

1. Jul 1, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     CMS health inspection

2. Dec 10, 2025 Health · 16 findings
   • Not serious Scope/severity D

     F0551 Resident Rights Deficiencies

     Give the resident's representative the ability to exercise the resident's rights.

     Corrected Jan 10, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0582 Resident Rights Deficiencies

     Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

     Corrected Jan 10, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Jan 10, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Jan 10, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Jan 10, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Jan 10, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Jan 10, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Jan 10, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Jan 10, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jan 10, 2026 · CMS health inspection

   • Not serious Scope/severity C

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Sep 5, 2026 · CMS fire safety

   • Not serious Scope/severity C

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Mar 31, 2026 · CMS fire safety

   • Not serious Scope/severity C

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Jan 10, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Jan 10, 2026 · CMS fire safety

   • Not serious Scope/severity C

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Jan 10, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Jan 10, 2026 · CMS fire safety

3. Oct 30, 2024 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

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

     Corrected Nov 30, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected Nov 30, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Nov 30, 2024 · CMS health inspection

4. Aug 21, 2024 Fire Safety · 23 findings
   • Not serious Scope/severity F

     E0013 Emergency Preparedness Deficiencies

     Develop Emergency Preparedness policies and procedures.

     Corrected Sep 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0020 Emergency Preparedness Deficiencies

     Establish policies and procedures including evacuation.

     Corrected Sep 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0035 Emergency Preparedness Deficiencies

     Provide family notifications of emergency plan.

     Corrected Sep 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Sep 23, 2024 · CMS fire safety

   • Not serious Scope/severity D

     F0623 Resident Rights Deficiencies

     Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

     Corrected Sep 23, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0625 Resident Rights Deficiencies

     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 Sep 23, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0640 Resident Assessment and Care Planning Deficiencies

     Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

     Corrected Sep 23, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Sep 23, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     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 Sep 23, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0223 Egress Deficiencies

     Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

     Corrected Sep 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0293 Egress Deficiencies

     Have properly located and lighted "Exit" signs.

     Corrected Sep 23, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Sep 23, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Sep 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Sep 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Sep 23, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Sep 23, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Sep 23, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Sep 23, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Sep 23, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Sep 23, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Sep 23, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0753 Miscellaneous Deficiencies

     Have restrictions on the use of highly flammable decorations.

     Corrected Sep 23, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0761 Miscellaneous Deficiencies

     To conduct inspection, testing and maintenance of fire doors by qualified individuals.

     Corrected Sep 23, 2024 · CMS fire safety

5. Jan 17, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Feb 17, 2024 · CMS health inspection

6. Sep 14, 2023 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0690 Quality of Life and Care Deficiencies

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

     Corrected Oct 16, 2023 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Oct 16, 2023 · CMS health inspection

7. Jun 7, 2023 Fire Safety · 19 findings
   • Not serious Scope/severity F

     E0031 Emergency Preparedness Deficiencies

     Provide emergency officials' contact information.

     Corrected Jul 7, 2023 · CMS fire safety

   • Not serious Scope/severity F

     E0032 Emergency Preparedness Deficiencies

     Provide primary/alternate means for communication.

     Corrected Jul 7, 2023 · CMS fire safety

   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Jul 7, 2023 · CMS fire safety

   • Not serious Scope/severity D

     F0580 Resident Rights Deficiencies

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

     Corrected Jul 7, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0644 Resident Assessment and Care Planning Deficiencies

     Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

     Corrected Jul 7, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Jul 7, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Jul 7, 2023 · CMS health inspection

   • Not serious Scope/severity F

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Jul 7, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0341 Smoke Deficiencies

     Install a fire alarm system that can be heard throughout the facility.

     Corrected Jul 7, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Jul 7, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jul 7, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0362 Smoke Deficiencies

     Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

     Corrected Jul 7, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Jul 7, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Jul 7, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Jul 7, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Jul 7, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0711 Miscellaneous Deficiencies

     Provide a written emergency evacuation plan.

     Corrected Jul 7, 2023 · CMS fire safety

   • Not serious Scope/severity C

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Jul 7, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0911 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the installation and maintenance of electrical systems.

     Corrected Jul 7, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• LANCOUR, DARRELL — w-2 managing employee, NOT APPLICABLE, since 01/01/2015
• LANCOUR, DARRELL — corporate officer, NOT APPLICABLE, since 03/01/2014
• LANCOUR, DARRELL — operational/managerial control, NOT APPLICABLE, since 03/01/2014
• ROWELL, CHARLES — w-2 managing employee, NOT APPLICABLE, since 12/31/2021
• NORTHLAND LUTHERAN RETIREMENT COMM — 5% or greater direct ownership interest, 100%, since 11/15/1988
• NORTHLAND LUTHERAN RETIREMENT COMM — operational/managerial control, NOT APPLICABLE, since 11/15/1988