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Complaint Investigation

Avera Morningside Heights Care Center

September 24, 2025 · Marshall, MN · 300 South Bruce Street
Citations 1
CMS Rating 3/5
Beds 76
Provider ID 245228
Healthcare Facility
Avera Morningside Heights Care Center
Marshall, MN  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

AVERA MORNINGSIDE HEIGHTS CARE CENTER in MARSHALL, MN — inspection on September 24, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0684
Quality of Life and Care Deficiencies
Immediate Jeopardy

jeopardy to resident health or safety

provide a medical evaluation, treatment and referral as appropriate.

This system could be utilized for a change in condition in a non-emergent situation and accessed 24 hours a day with the resident's primary provider (PCP) being notified of the use of Avel virtual services and the resident's condition.

The December 2024, Chain of Command and Administrative Call policy identified staff who have identified a problem situation would collaborate with their peers to determine the urgency of the problem.

The responsible provider would be contacted for clarification. If the problem remained unresolved, the staff were to seek guidance of the LTC charge nurse.

The charge nurse would contact the responsible provider. If the concern continues to be unresolved and there was an immediate risk to the resident care and safety, the charge nurse was to contact the LTC leader on-call if on a weekend, or the director of nursing on a weekday.

The findings would be reviewed and if needed, the LTC leader on call or administrator would call for further clarification and discussion. If the issue remains unresolved, the administrator would be contacted and they would notify the chief medical officer, if needed, for assistance.

The undated, E-Care and emergency room Services policy identified for a resident experiencing an injury or illness, the nurse was to assess and determine the best course of action for the resident.

Staff were to address E-Care services with the resident and family. If staff were unable to contact family and/or resident was unable to make their needs known, staff had the right to send the resident to the emergency room.

The nurse may contact E-Care for all non-emergent needs to confer with an on-call provider.

The nurse had a right to utilize the emergency department based on their clinical judgement and assessment. A physician's order was not required to send a resident into the emergency room for evaluation. If a nurse was in doubt about whether to pursue further medical care, they were to collaborate with another nurse.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MARSHALL, MN, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from AVERA MORNINGSIDE HEIGHTS CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.