Cycle 1
Health 2025-03-06 · Fire 2025-03-06
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Plymouth, MN
Allina Health Restorative Suites
5-star overall rating with 3-star inspections with 3 recent health deficiencies
2775 Campus Drive North, Plymouth, MN
(763) 577-3400
Overall
5 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
46
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2015-04-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
2.46
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.31
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
5.40
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
3.08
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.43
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
1.47
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.30
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
2.44
CMS adjusted RN staffing hours
Adjusted total hours
5.35
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,561
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55.69
Composite VBP score used to determine payment impact.
Payment multiplier
1.0107
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.46% · Performance 22.16% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
7.90
Baseline 6.03% · Performance 5.47% · Measure score 7.90 · Achievement 7.90 · Improvement 4.90
Total nurse turnover
6.82
Baseline 45.59% · Performance 35.82% · Measure score 6.82 · Achievement 6.82 · Improvement 4.21
Adjusted total nurse staffing
7.56
Baseline 5.22 hours · Performance 5.23 hours · Measure score 7.56 · Achievement 7.56 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.18% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 583 · Observed rate 8.58% · Lower 95% interval 9.31% |
| Discharge to community | 67.31% |
50.57%
16.7 pts better
|
Better than the National Rate · Eligible stays 631 · Observed rate 71% · Lower 95% interval 65.22% |
| Medicare spending per beneficiary | 0.76 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 332 · Denominator 332 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 332 |
| Discharge self-care score | 72.86% |
53.69%
19.2 pts better
|
Numerator 204 · Denominator 280 |
| Discharge mobility score | 69.64% |
50.94%
18.7 pts better
|
Numerator 195 · Denominator 280 |
| Pressure ulcers or injuries, new or worsened | 0.6% |
2.29%
1.7 pts better
|
Numerator 2 · Denominator 332 · Adjusted rate 0.93% |
| Healthcare-associated infections requiring hospitalization | 5.47% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 338 · Observed rate 3.25% · Lower 95% interval 3.56% |
| Staff COVID-19 vaccination coverage | 22.92% |
8.2%
14.7 pts better
|
Numerator 33 · Denominator 144 |
| Staff flu vaccination coverage | 45.9% |
42%
3.9 pts better
|
Numerator 84 · Denominator 183 |
| Discharge function score | 83.21% |
56.45%
26.8 pts better
|
Numerator 233 · Denominator 280 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 28 · Denominator 28 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 298 · Denominator 298 |
| Resident COVID-19 vaccinations up to date | 29.3% |
25.2%
4.1 pts better
|
Numerator 46 · Denominator 157 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
88.6%
10.8 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 99.3% · Q3 100.0% · Q4 99.8% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.9% |
14.0%
1.9 pts worse
|
12.0%
3.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.9% · Observed 14.2% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.9%
1.1 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.6% · Q3 1.1% · Q4 0.9% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.7% |
82.7%
15 pts better
|
79.7%
18 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.8% |
23.1%
6.3 pts better
|
23.9%
7.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.8% · Observed 13.5% · Expected 19.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-11 · Fire 2024-01-11
9 health deficiencies
Top issue: Infection Control (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-02-01 · Fire 2023-02-01
6 health deficiencies
Top issue: Resident Rights (3 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-01-11
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-02-21
F · Potential for more than minimal harm
2024-01-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-21
F · Potential for more than minimal harm
2024-01-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-02-21
F · Potential for more than minimal harm
2024-01-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-21
C · Minimal harm
2024-01-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-21
F · Potential for more than minimal harm
2023-02-01
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-03-13
F · Potential for more than minimal harm
2023-02-01
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-03-13
F · Potential for more than minimal harm
2023-02-01
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-03-13
F · Potential for more than minimal harm
2023-02-01
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-03-13
E · Potential for more than minimal harm
2023-02-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-28
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-08-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-15
J · Immediate jeopardy
2025-08-12
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-08-10
E · Potential for more than minimal harm
2024-01-11
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-11
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-11
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-11
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-11
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-11
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-21
D · Potential for more than minimal harm
2024-01-11
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-02-21
D · Potential for more than minimal harm
2023-10-09
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-10-27
J · Immediate jeopardy
2023-02-01
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-03-13
F · Potential for more than minimal harm
2023-02-01
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-03-13
D · Potential for more than minimal harm
2023-02-01
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-03-13
D · Potential for more than minimal harm
2023-02-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-13
D · Potential for more than minimal harm
2023-02-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-03-13
Penalties and ownership
What sits behind the stars
Ownership
Allina Health System
5% Or Greater Direct Ownership Interest · Organization
Cassia
Operational/Managerial Control · Organization
Cox, Clarissa
Corporate Director · Individual
Downing, Emily
Operational/Managerial Control · Individual
Downing, Emily
Corporate Director · Individual
Downing, Emily
Corporate Officer · Individual
Holton, Colleen
Corporate Director · Individual
Holton, Colleen
Corporate Officer · Individual
Plunkett, Rodney
Corporate Director · Individual
Rose, Cade
Operational/Managerial Control · Individual
Tallarico, Dominica
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Mission Nursing Home
Plymouth, MN
3-star overall rating with 2-star inspections with 10 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Good Samaritan Ambassador
New Hope, MN
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
The Birches at Trillium Woods
Plymouth, MN
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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