S&C QCOR HHA 2567s
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HHAs 2567s
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Time Interval

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Provider Characteristics

Use these filters if you want to limit the report to providers that have certain characteristics. To select more than one option, hold down the Ctrl (individual point-and-click) OR Shift keys (select through a range) while you click on the additional desired option(s).

Survey Type & Deficiency Tags

Use these filters if you want to limit the reports to providers on specific survey types, or to reports that were cited for specific HHA deficiency tags and tag types. To select more than one option, hold down the Ctrl (individual point-and-click) OR Shift keys (select through a range) while you click on the additional desired option(s).

CCN and Facility Name

Use these filters if you know the name (or partial name) of the facility you are searching for, or the CMS Certification Number (CCN) for the facility you are searching for.

Other Survey Characteristics

Select one of the options below to filter by surveys that cite deficiencies or by surveys that are deficiency-free. By default, only surveys that cite deficiencies are displayed. Selecting "All" displays all surveys.

CMS Certification Number Facility Name Address City State CMS Region Date of CMS Survey Survey Event ID Survey Type Statement of Deficiencies Report
▼ 247223 Deer River Healthcare Center, Inc. 115 10th Avenue Northeast Deer River MN 5 (Chicago) 01/28/2025 64AF5-H1 Recertification
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not a Deficiency Citation Memo
G0000 Initial Comments - Not a Deficiency Citation Memo
E0001 Establishment of the Emergency Program (EP) Condition
G0940 Organization and administration of services Condition
E0004 Develop EP Plan, Review and Update Annually Standard
E0013 Development of EP Policies and Procedures Standard
E0036 EP Training and Testing Standard
G0982 Skilled services furnished Standard
▼ 247223 Deer River Healthcare Center, Inc. 115 10th Avenue Northeast Deer River MN 5 (Chicago) 05/12/2022 38573-H1 Recertification
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not a Deficiency Citation Memo
G0000 Initial Comments - Not a Deficiency Citation Memo
G0578 Conformance with physician orders Standard
G0434 Participate in care Element
G0514 RN performs assessment Element
G0548 Within 48 hours of the patient's return Element
G0574 Plan of care must include the following Element
G0576 All orders recorded in plan of care Element
G0580 Only as ordered by a physician Element
G0710 Provide services in the plan of care Element
▼ 247223 Deer River Healthcare Center, Inc. 115 10th Avenue Northeast Deer River MN 5 (Chicago) 05/22/2020 UEQO11 Focused Infection Control, Other-Fed
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not a Deficiency Citation Memo
G0000 Initial Comments - Not a Deficiency Citation Memo
G0682 Infection Prevention Standard
▼ 247223 Deer River Healthcare Center, Inc. 115 10th Avenue Northeast Deer River MN 5 (Chicago) 08/08/2019 NI3911 Recertification
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not a Deficiency Citation Memo
G0000 Initial Comments - Not a Deficiency Citation Memo
G0572 Plan of care Standard
G0514 RN performs assessment Element
G0808 Onsite supervisory visit every 14 days Element
▼ 247224 Ecumen Home Care - Pathstone 718 Mound Avenue Mankato MN 5 (Chicago) 08/10/2023 60571-H1 Recertification
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not a Deficiency Citation Memo
G0000 Initial Comments - Not a Deficiency Citation Memo
G0574 Plan of care must include the following Element
G0708 Development and evaluation of plan of care Element
▼ 247226 Spring Valley Home Hlth Agency 800 Memorial Drive Spring Valley MN 5 (Chicago) 09/26/2023 605EE-H1 Complaint, Recertification
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not a Deficiency Citation Memo
G0000 Initial Comments - Not a Deficiency Citation Memo
G0940 Organization and administration of services Condition
G1008 Clinical records Condition
G0982 Skilled services furnished Standard
G1026 Retention of records Standard
G1030 Retrieval of records Standard
▼ 247226 Spring Valley Home Hlth Agency 800 Memorial Drive Spring Valley MN 5 (Chicago) 09/06/2018 J02E11 Recertification
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not a Deficiency Citation Memo
G0000 Initial Comments - Not a Deficiency Citation Memo
G0536 A review of all current medications Element
G0574 Plan of care must include the following Element
G0580 Only as ordered by a physician Element
G0808 Onsite supervisory visit every 14 days Element
G0814 Non-skilled direct observation every 60 days Element
▼ 247227 Rolen Cares Llc 1111 Cloquet Ave, Ste. #3 Cloquet MN 5 (Chicago) 09/17/2025 1D6B86-H1 Complaint
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not a Deficiency Citation Memo
G0000 Initial Comments - Not a Deficiency Citation Memo
G0570 Care planning, coordination, quality of care Condition
E0036 EP Training and Testing Standard
G0372 Encoding and transmitting OASIS Standard
G0564 Discharge or Transfer Summary Content Standard
G0572 Plan of care Standard
G0684 Infection control Standard
G0768 Competency evaluation Standard
G0774 12 hours inservice every 12 months Standard
G0514 RN performs assessment Element
G0536 A review of all current medications Element
G0590 Promptly alert relevant physician of changes Element
▼ 247227 Rolen Cares Llc 1111 Cloquet Ave, Ste. #3 Cloquet MN 5 (Chicago) 11/14/2024 646CA-H1 Recertification
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not a Deficiency Citation Memo
G0000 Initial Comments - Not a Deficiency Citation Memo
E0001 Establishment of the Emergency Program (EP) Condition
E0004 Develop EP Plan, Review and Update Annually Standard
E0013 Development of EP Policies and Procedures Standard
E0029 Development of Communication Plan Standard
E0036 EP Training and Testing Standard
G0418 Patient's or legal representative's signature Element
G0434 Participate in care Element
G0464 Advise the patient of discharge for cause Element
G0466 Make efforts to resolve the problem(s) Element
G0468 Provide contact info other services Element
G0470 Document efforts to resolve problems Element
G0514 RN performs assessment Element
G0580 Only as ordered by a physician Element
G0588 Reviewed, revised by physician every 60 days Element
G0598 Discharge plans communication Element
G0800 Services provided by HH aide Element
G0808 Onsite supervisory visit every 14 days Element
▼ 247227 Rolen Cares Llc 1111 Cloquet Ave, Ste. #3 Cloquet MN 5 (Chicago) 06/03/2022 388FB-H1 Recertification
Deficiency Tag Deficiency Description Tag Type
E0000 Initial Comments - Not a Deficiency Citation Memo
G0000 Initial Comments - Not a Deficiency Citation Memo
E0024 Policies/Procedures-Volunteers and Staffing Standard
E0032 Primary/Alternate Means for Communication Standard
G0578 Conformance with physician orders Standard
G0684 Infection control Standard
G0434 Participate in care Element
G0598 Discharge plans communication Element
G0710 Provide services in the plan of care Element