Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Heritage Manor
CHISHOLM, MN · 65 certified beds · Last Life Safety survey June 26, 2025
CMS Certification Number 245245 · first certified September 1982
Ownership
Operated by ST. FRANCIS HEALTH SERVICES · Non profit - Church related
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within MN
25 citations — more than 90% of the 338 certified nursing homes in MN. Compared within MN rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 9 citations; the earlier surveys in the window averaged 8. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (May 2026 to August 2026), and past the point by which nine in ten MN facilities have been surveyed. This facility’s last Life Safety survey was June 2025. Facilities in MN are typically surveyed 11–14 months after the last one (median 13), measured over 613 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
1 of the 25 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 25 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in MN, and nationally. Surveyors differ markedly between states, so the MN figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 25 |
| Median facility in MN | 12 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| March 9, 2023 | 5 |
| May 16, 2024 | 11 |
| June 26, 2025 | 9 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2025-06-26 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2024-05-16 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2025-06-26 |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | 2 | 2025-06-26 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2025-06-26 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2025-06-26 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 1 | 2025-06-26 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2025-06-26 |
What the citations cover
- Smoke Deficiencies 9
- Egress Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Miscellaneous Deficiencies 4
- Other 3
| Category | Citations |
|---|---|
| Smoke Deficiencies | 9 |
| Egress Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Miscellaneous Deficiencies | 4 |
| Services Deficiencies | 2 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 26, 2025 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (August 20, 2025) |
| K-0226 | Have horizontal exits used in accordance with safety requirements. | Deficient, Provider has date of correction (August 20, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (August 20, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (August 20, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (August 20, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (August 20, 2025) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (August 20, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (August 20, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (August 20, 2025) |
May 16, 2024 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (July 1, 2024) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (July 1, 2024) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (July 1, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 1, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (July 1, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (July 1, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (July 1, 2024) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (July 1, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (July 1, 2024) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (July 1, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (July 1, 2024) |
March 9, 2023 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (April 17, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (April 17, 2023) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (April 17, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 17, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (April 17, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.