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🔎 Centracare Health System - Melrose Pine Villa C C

Inspection Results


Inspection Overview

Centracare Health System - Melrose Pine Villa C C has been cited for a total of 21 deficiencies since we began saving each survey.

In Minnesota, the average facility has **36.42 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2025-04-28
Correction Date: 2025-06-09
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Survey Date: 2024-08-29
Correction Date: 2024-09-24
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2024-08-29
Correction Date: 2024-09-24
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that residents are fully informed and understand their health status, care and treatments.

Survey Date: 2023-08-10
Correction Date: 2023-09-18
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

PASARR screening for Mental disorders or Intellectual Disabilities

Survey Date: 2022-09-22
Correction Date: 2022-10-13
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2022-09-22
Correction Date: 2022-10-13
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: F

Perform COVID19 testing on residents and staff.

Survey Date: 2022-06-28
Correction Date: 2022-08-02
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2020-10-08
Correction Date: 2020-11-25
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2020-07-14
Correction Date: 2020-08-07
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2019-08-15
Correction Date: 2019-09-24
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Survey Date: 2019-08-15
Correction Date: 2019-09-24
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-08-15
Correction Date: 2019-09-24
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2019-08-15
Correction Date: 2019-09-24
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: E

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Survey Date: 2019-08-15
Correction Date: 2019-09-24
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2019-08-15
Correction Date: 2019-09-24
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Survey Date: 2019-08-15
Correction Date: 2019-09-24
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2018-06-28
Correction Date: 2018-07-18
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2018-06-28
Correction Date: 2018-07-26
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: C

Post nurse staffing information every day.

Survey Date: 2018-06-28
Correction Date: 2018-07-26
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2018-06-28
Correction Date: 2018-07-18
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2018-06-28
Correction Date: 2018-07-26
Category: Infection Control Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**