Renvilla Health Center
205 Southeast Elm Avenue, Renville, MN 56284 · Non profit - Corporation · 38 certified beds · (320) 329-8381 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no harm-level citations in the current inspection record
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (28% vs 45% nationally) — better care continuity
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 4 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 21.9% | 18.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.4% | 4.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.7% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 3.9% | 2.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 4.1% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.1% | 4.0% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 22.7% | 20.5% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 3.3% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.0% | 5.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 25.4% | 24.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.0% | 17.1% | 17.1% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.20 therapist hours per resident per day in 2026Q1 — more than 21% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 38 beds and averages 30.8 residents a day — about 81% occupied, or roughly 7 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.93 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.84 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.69 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.60 hrs/resident/day on weekends vs 4.06 on weekdays — 11% thinner on weekends. RN hours go from 1.01 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 28% is below the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
11 citations, most serious first — scroll within the box to see all.
- Potential for harm · D2026-06-15 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to ensure 1 of 5 sampled residents (R12) had completed tuberculosis (TB) testing upon admission.Findings include: R12's admission record identified that R12 had been admitted to the facility in March of 2026 for skilled nursing services. R12's 5/11/26, progress note identified an (an interferon-gramma (IGA) release assay test) aka a T-spot was drawn. There was no further documentation in the progress notes to identify if the test was delivered to the laboratory, or what the results of that test were. There was also no indication the facility had tested R12 upon admission to the facility in March 2026, versus a delated test in May 2026. Interview on 6/15/26 at 5:18 p.m., with director of nursing identified the facility had been completing audits related to missing some TB testing and they must have missed R12 during that audit process. She identified that R12 had blood drawn to complete a T-spot test for TB; however, the facility forgot to send a form along with the sample to the lab identifying who the blood sample was from…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-10 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to notify the physician of new wounds for 1 of 3 residents (R1) reviewed for pressure ulcers and impaired skin integrity. Findings include:R1's face sheet identified diagnoses of non-ST elevation myocardial infarction (heart attack from blockage of artery), chronic atrial fibrillation (heart flutter), cellulitis (bacterial infection) of left lower limb, type 2 diabetes, stage 5 chronic kidney disease dependent on renal dialysis, left below knee amputation, and cardiomyopathy (heart disease).R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 did not have cognitive impairment, no behaviors, but would reject evaluation or care four to six days. R1 required maximum to complete assistance with activities of daily living. R1 had one stage two pressure ulcer on admission (right lateral foot). R1's facility admission skin/wound assessment dated [DATE], identified fourteen wounds. One of the fourteen wounds assessed identified a blister to right…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-10 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to incorporate skin integrity interventions into care plans for 2 of 3 residents (R1, R2) who were reviewed for skin.Findings include: R1's face sheet identified diagnoses of non-ST elevation myocardial infarction (heart attack from blockage of artery), chronic atrial fibrillation (heart flutter), cellulitis (bacterial infection) of left lower limb, type 2 diabetes, stage 5 chronic kidney disease dependent on renal dialysis, left below knee amputation, cardiomyopathy (heart disease), sleep apnea, and hypertension.R1's admission Minimum Data Set (MDS) dated [DATE], identified no cognitive deficits, no behaviors, but would reject evaluation or care four to six days. R1 required maximum to complete assistance with activities of daily living. R1 had one stage two pressure ulcer on admission (right lateral foot). Care Area Assessment (CAA) triggered pressure ulcer, care planning decision dated 10/20/25.R1's facility admission skin/wound assessment dated [DATE],…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-10 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to initiate, monitor, and notify the physician of wounds for 1 of 1 resident (R1) who was assessed on admission to have multiple wounds reviewed for impaired skin integrity.Findings include:R1's face sheet identified diagnoses of non-ST elevation myocardial infarction (heart attack from blockage of artery), chronic atrial fibrillation (heart flutter), cellulitis (bacterial infection) of left lower limb, type 2 diabetes, stage 5 chronic kidney disease dependent on renal dialysis, left below knee amputation, and cardiomyopathy (heart disease). R1's hospital Discharge summary dated [DATE], identified six skin issues on discharge but did not identify skin injury to right 4th toe. Wounds identified included: 1. Full thickness wound due to infection/edema of left residual limb2. Full thickness wound to right leg (edema)3. Right ear (unclear)4. Right arm/back/neck (trauma)5. Non-pressure open wounds due to perforating dermatitis of right anterior leg and left…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to identify and comprehensively assess a pressure ulcer for 1 of 3 residents (R3) reviewed for pressure ulcers. Findings include:R3's face sheet dated 10/22/25, identified diagnoses of fracture of lower end of right femur, type 2 diabetes.R3's admission Minimum Data Set (MDS) dated [DATE], identified no cognition issue, refused cares four to six days a week, substantial assistance with activities of daily living, always incontinent of bowel and bladder, and had no skin conditions.R3's care plan dated 7/10/25, identified impairment to skin integrity. Interventions included to encourage good nutrition and hydration to promote healthier skin, and skin treatments per provider, update as needed. Check all of body for breaks in skin and treat promptly.R3's Braden scale dated 7/30/25, identified a score of 15, which is at risk for skin impairment.R3's skin and wound evaluation dated 10/21/25, did not identify an open area to R3's coccyx.R3's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-21 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and document review the facility failed to revise 1 of 1 resident's (R2) care plan when his nutritional status changed. R2's 9/8/25 admission Minimum Data Set assessment identified his cognition was severely impaired. He had diagnoses of malnutrition, encephalitis and encephalomyelitis (inflammations of the brain and spinal cord), meningitis (inflammation of protective layer around brain and spinal cord), type II diabetes, disorientation, and anxiety. He was dependent on staff for all activities of daily living and required total assist with meals. Observation on 9/15/25 at 11:59 a.m., in the dining room, R2 was seated in his wheelchair, he was slouched over with his eyes closed and appeared to be sleeping. He was approximately 2 feet from the dining room table where his meal was sitting. Staff approached him, woke him up, and moved him and his food to a different table to assist him with meal. Interview on 9/16/25 at 1:13 p.m., with nursing assistant (NA)-B identified they let R2 feed himself and when he stops eating and taps his fork on the table…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-08-27 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prepare food under sanitary conditions, discard food that had been expired, ensure all foods were labeled and dated, and ensure the freezer door had been shit to prevent potential spoiling of food. This had the potential to affect all 39 residents. During observation and interview with cook-A and later joined by the dietary manager on 8/25/24 at 11:30 a.m., the following was observed during the initial tour of the kitchen: 1. Mrs. Gerry's Parmesan Pepper Corn Pasta Salad had been previously opened with an expiration date of 8/17/24. 2. Mustard with a use by date of 12/10/22 3. Bag of California Sun Dried Raisins, best before 4/6/24. 4. Minced garlic in a squeeze bottle with no visible expiration date, bottle had a dark brown substance on the inside of the lid and around the opening and a black substance on the outside of the bottle. 5. A second bottle of minced garlic with a use by date printed on the bottom of 8/11/23 6. A bottle of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-08-27 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review the facility failed to implement 1 of 1 facility assessment protocol related to ensuring staff competencies were identified and completed respective to staff duties performed. The facility assessment protocol further failed to solicit input from staff, residents, representatives, or family members. Refer to F812 Findings include: Review of the 8/8/24, facility assessment identified changes which were highlighted in yellow that went into effect on 8/8/24. The changes included solicitation of feedback: questionnaire to resident/representative related to staffing, suggestion boxes throughout facility, annual notices to residents/representative prior to annual review, review during resident/family council meeting, departmental/all staff meetings. Accepting residents not on the assessment-add prior to admission. Competencies-knowledge and skills able to prove (demonstration) for hired staff, temporary staff, volunteers, and vendors. On the page identified as authorizations and resident profile listed persons assisting in completing assessment,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-08-27 · tag F0867 — failed to act on quality-improvement findings — widespreadSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to have evidence of measurable goals and documentation of an analysis and evaluation of the data submitted to the QAPI committee to ensure areas identified had oversight for their perspective outcomes brought forth for 1 of 1 Quality Assurance Performance Improvement (QAPI) program. Findings include: Review of the 2/14/24, monthly QAPI meeting minutes identified the facility departments were submitting data to be reviewed by the committee. 2 examples of failure to document a measurable goal and/or analyze the data identified: 1) Quality improvement Incentive Program (QIIP) Bowel incontinence with toileting plan identified residents with bowel incontinence triggering would be reviewed for toileting habits and interviews with staff would be completed. The individualized toileting plans would be reviewed. The director of nursing (DON), assistant director of nursing (ADON) and the MDS coordinator would be assigned the review. Completion date was ongoing.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-27 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and document review the facility failed to appropriately administer and accurately reconcile 1 of 1 resident's (R35) medication (lisinopril) (used for high blood pressure) when the order was changed and prior to administering any medication. Findings include: Observation, interview, and Medication Administration Record (MAR) review on 8/27/24 at 9:14 a.m., with trained medication aid (TMA)-A as she prepared to administer morning medications to R35 identified TMA-A removed R35's medication cards from the medication cart and placed them on top of the cart. She accessed the electronic medical record (EMR) which Displayed R35's current medication orders. TMA- A picked up a card, looked at the order on the screen, and popped the medication into a waiting medication cup. When TMA-A picked up the card containing the lisinopril she looked at the card, glanced at the screen, and prepared to place the lisinopril into the medication cup with the meds to be administered. TMA-A was asked what the order was for the lisinopril and looking at the EMR responded, the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-27 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and document review, the facility failed to ensure an accurate labeling of three medication for two residents (R35 and R38), who had medication package labels and orders that did not match or give clear direction, to avoid the potential medication errors. Findings included: R35's current 8/26/24 physician order for lisinopril ( a blood pressure medication) listed 5 milligrams (mg) by mouth (PO) daily (QD). The medication card located with R35's active medications contained 10 mg tablets. The bubble packaged medication card had no label, or identification of a change in order, or dosage. R38's current Physician Order Summary contained a 6/18/24 order for Gabapentin ( used to treat neuropathic pain) oral capsule 100 mg, 3 capsules PO twice daily (BID) (7:00 a.m.-10:00 a.m. and 7:00 p.m. - 10:00 p.m.) and 100 mg PO QD (12:00 p.m.-2:30 p.m.). The current medication card contained 300 mg capsules and directed staff to administer one capsule PO BID. The card failed to contain any label or notation to draw attention to the dosage of the medication in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to ST. FRANCIS HEALTH SERVICES — 14 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 2.8 | +2.2 vs chain |
| Health inspection | 4 of 5 | 2.2 | +1.8 vs chain |
| Staffing | 5 of 5 | 4.6 | +0.4 vs chain |
| Quality measures | 2 of 5 | 2.9 | -0.9 vs chain |
The other 13 homes this chain runs (chain average 2.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| DRIPPS, DANIEL | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2016 |
| EHLERS, DOUGLAS | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2023 |
| GOODNOUGH, JENNIFER | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2021 |
| GRAMM, TIMOTHY | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2023 |
| LAIR, MICHAEL | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| LIENEMANN, STEVEN | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| LUETMER, JOHN | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2021 |
| NELSON, PATRICK | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2020 |
| RENTZ, LAURA | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2024 |
| RENTZ, PAUL | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2021 |
| SCHNEIDER, TODD | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/01/2013 |
| WIESE, LORRAINE | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/25/2017 |
| BACH, CURTIS | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/28/2024 |
| HOFMANN, REED | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/08/2023 |
| RAW, CAROL | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/16/2005 |
| AEGIS THERAPIES, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/01/2019 |
| EIDE BAILLY LLP | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/03/2023 |
| ST. FRANCIS HEALTH SERVICES OF MORRIS, INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/05/2005 |
| BAKKE, CHRISTINE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/30/2019 |
| BURROWS, AMANDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/02/2024 |
| CASPERS, MEGAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/29/2014 |
| FREIBORG, ELIZABETH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/23/2004 |
| GJERMUNDSON, JOHN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/26/2020 |
| HANNEKEN, MICHELLE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/20/2022 |
| HANSON, SHANNON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/15/2002 |
| HEJHAL, ROXANNE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/10/2023 |
| HUSETH, KENDRA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/26/2024 |
| JENNIGES, REBECCA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/12/2025 |
| KEMP, JON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| KUBESH, ZACHARY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/10/2025 |
| MARLOW, JINA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/06/2022 |
| MCCLEERY, REBECCA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| MCLEOD, ELIZABETH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/28/2025 |
| PETERSON-DEVRIES, CAMI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/08/2022 |
| RENTZ, MARK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/22/2024 |
| RYAN, BEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/27/2012 |
| STOCK, KELSEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2022 |
| THOMPSON, RENEE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/10/2018 |
| TOMOSON, APRIL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/12/2021 |
| WALKER, AMY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/13/2024 |
| HEDMAN, MELINDA | Individual | ADP OF THE SNF | since 05/20/2025 |
CMS files one row per role, so the 110 rows in the source record cover these 41 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $267K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Minnesota Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 245554. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-15, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.