Cycle 1
Health 2024-11-07 · Fire 2024-11-07
0 health deficiencies
No concentrated health issue counts in this cycle.
5 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cold Spring, MN
Assumption Home
5-star overall rating with 5-star inspections with 5 fire-safety deficiencies in the latest cycle
715 North First Street, Cold Spring, MN
(320) 685-3693
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
76
Certified beds
Average residents
73
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Benedictine Health System
Operator or chain grouping
Approved since
1987-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
22 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.65
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.60
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.76
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.01
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.25
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.58
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.73
CMS adjusted RN staffing hours
Adjusted total hours
4.54
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
10%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,569
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.24
Composite VBP score used to determine payment impact.
Payment multiplier
0.9816
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.67% · Performance 21.34% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.73% · Performance 8.08% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0.86
Baseline 56.98% · Performance 60.18% · Measure score 0.86 · Achievement 0.86 · Improvement 0
Adjusted total nurse staffing
5.64
Baseline 4.24 hours · Performance 4.68 hours · Measure score 5.64 · Achievement 5.64 · Improvement 2.38
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.98% |
10.72%
1.7 pts better
|
No Different than the National Rate · Eligible stays 104 · Observed rate 4.81% · Lower 95% interval 6.02% |
| Discharge to community | 62.22% |
50.57%
11.6 pts better
|
Better than the National Rate · Eligible stays 101 · Observed rate 58.42% · Lower 95% interval 51.22% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.44% |
95.27%
3.2 pts better
|
Numerator 63 · Denominator 64 |
| Falls with major injury | 1.56% |
0.77%
0.8 pts worse
|
Numerator 1 · Denominator 64 |
| Discharge self-care score | 74% |
53.69%
20.3 pts better
|
Numerator 37 · Denominator 50 |
| Discharge mobility score | 80% |
50.94%
29.1 pts better
|
Numerator 40 · Denominator 50 |
| Pressure ulcers or injuries, new or worsened | 3.13% |
2.29%
0.8 pts worse
|
Numerator 2 · Denominator 64 · Adjusted rate 3.9% |
| Healthcare-associated infections requiring hospitalization | 8.08% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 10% · Lower 95% interval 5.09% |
| Staff COVID-19 vaccination coverage | 4% |
8.2%
4.2 pts worse
|
Numerator 8 · Denominator 200 |
| Staff flu vaccination coverage | 11.21% |
42%
30.8 pts worse
|
Numerator 25 · Denominator 223 |
| Discharge function score | 76% |
56.45%
19.5 pts better
|
Numerator 38 · Denominator 50 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 27 · Denominator 27 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 38.89% |
25.2%
13.7 pts better
|
Numerator 14 · Denominator 36 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.7
0.1 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.6 · Expected 2.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
2.0
0.9 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.3 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.3%
2.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.9% |
96.1%
0.8 pts better
|
95.5%
1.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.8% |
3.9%
3.1 pts better
|
3.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 1.6% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.7% |
4.3%
1.4 pts worse
|
11.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 4.3% · Q3 6.5% · Q4 7.4% · 4Q avg 5.7% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
4.1%
4.1 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.1% |
12.4%
5.3 pts better
|
19.6%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 8.8% · Q3 7.7% · Q4 8.7% · 4Q avg 7.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.5% |
17.5%
4 pts better
|
16.7%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 14.3% · Q3 15.6% · Q4 16.2% · 4Q avg 13.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.8% |
22.5%
1.7 pts better
|
16.3%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 17.3% · 4Q avg 20.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.3% |
18.6%
2.7 pts worse
|
14.9%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 27.6% · Q3 14.3% · Q4 25.6% · 4Q avg 21.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
2.3%
1.6 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
2.6%
1.4 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 1.7% · Q4 1.6% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.4% |
24.8%
0.6 pts worse
|
19.8%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.9% · Q2 28.7% · Q3 19.8% · Q4 28.4% · 4Q avg 25.4% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
5.4%
0.8 pts worse
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 7.9% · Q3 5.7% · Q4 5.9% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
88.6%
7.9 pts better
|
81.7%
14.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 96.4% · Q3 96.5% · Q4 97.4% · 4Q avg 96.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.4% |
14.0%
8.6 pts better
|
12.0%
6.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.4% · Observed 5.0% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
82.7%
17.3 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.5% |
23.1%
0.6 pts better
|
23.9%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.5% · Observed 16.7% · Expected 17.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-01 · Fire 2023-11-01
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-01-19 · Fire 2023-01-19
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-11-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-30
E · Potential for more than minimal harm
2024-11-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-30
D · Potential for more than minimal harm
2024-11-07
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-11-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-30
D · Potential for more than minimal harm
2024-11-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-30
F · Potential for more than minimal harm
2023-01-19
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2023-02-06
D · Potential for more than minimal harm
2023-01-19
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2023-02-01
Inspection history
Recent health citations
G · Actual harm
2024-08-14
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 2024-08-13
D · Potential for more than minimal harm
2024-05-14
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-06-12
D · Potential for more than minimal harm
2023-11-01
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 2023-12-01
B · Minimal harm
2023-11-01
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-12-01
F · Potential for more than minimal harm
2023-01-19
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-03-02
F · Potential for more than minimal harm
2023-01-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-02
D · Potential for more than minimal harm
2023-01-19
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-03-02
D · Potential for more than minimal harm
2023-01-19
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-03-02
D · Potential for more than minimal harm
2023-01-19
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-03-02
D · Potential for more than minimal harm
2023-01-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-03-02
D · Potential for more than minimal harm
2023-01-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-02
D · Potential for more than minimal harm
2023-01-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-02
D · Potential for more than minimal harm
2023-01-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-03-02
D · Potential for more than minimal harm
2023-01-19
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2023-03-02
D · Potential for more than minimal harm
2023-01-19
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-03-02
Penalties and ownership
What sits behind the stars
Ownership
Benedictine Health System
5% Or Greater Direct Ownership Interest · Organization
Benedictine Health System
Operational/Managerial Control · Organization
Bergien, Tricia
Corporate Officer · Individual
Carley, Gerald
Corporate Director · Individual
Frie, Adam
Corporate Director · Individual
Holthaus, Nicole
Corporate Director · Individual
Major, Anne
Contracted Managing Employee · Individual
Peterson, Anneliese
Corporate Director · Individual
Rymanowski, Kevin
Corporate Director · Individual
Schaefer, Heather
W-2 Managing Employee · Individual
Scheierl, Leroy
Corporate Director · Individual
Stang, Merilee
Corporate Director · Individual
Watkins, Douglas
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Hilltop Health Care Center
Watkins, MN
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
#2
Sterling Park Health Care Center
Waite Park, MN
2-star overall rating with 2-star inspections with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Mother of Mercy Senior Living
Albany, MN
2-star overall rating with 2-star inspections with $106,845 in total fines with 12 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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