Cycle 1
Health 2025-12-03 · Fire 2025-12-03
4 health deficiencies
Top issue: Infection Control (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Marshall, MN
Avera Morningside Heights Care Center
3-star overall rating with 2-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
300 South Bruce Street, Marshall, MN
(507) 537-9394
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 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
Avera Health
Operator or chain grouping
Approved since
1979-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
12 facilities
Chain averages 4 overall / 3 health / 5 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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.94
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.41
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
3.64
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
5.00
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.55
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.62
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
1.04
CMS adjusted RN staffing hours
Adjusted total hours
5.51
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
26%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,231
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.79
Composite VBP score used to determine payment impact.
Payment multiplier
0.9937
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.49
Baseline 18.72% · Performance 20.28% · Measure score 2.49 · Achievement 2.49 · Improvement 0
Healthcare-associated infections
0.56
Baseline 5.49% · Performance 7.67% · Measure score 0.56 · Achievement 0.56 · Improvement 0
Total nurse turnover
7.15
Baseline 34.04% · Performance 34.44% · Measure score 7.15 · Achievement 7.15 · Improvement 0
Adjusted total nurse staffing
6.12
Baseline 4.47 hours · Performance 4.82 hours · Measure score 6.12 · Achievement 6.12 · Improvement 2.16
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.56% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 149 · Observed rate 9.4% · Lower 95% interval 7.29% |
| Discharge to community | 62.01% |
50.57%
11.4 pts better
|
Better than the National Rate · Eligible stays 133 · Observed rate 59.4% · Lower 95% interval 53.74% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 115 · Denominator 115 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 115 |
| Discharge self-care score | 76.53% |
53.69%
22.8 pts better
|
Numerator 75 · Denominator 98 |
| Discharge mobility score | 81.63% |
50.94%
30.7 pts better
|
Numerator 80 · Denominator 98 |
| Pressure ulcers or injuries, new or worsened | 7.83% |
2.29%
5.5 pts worse
|
Numerator 9 · Denominator 115 · Adjusted rate 10.49% |
| Healthcare-associated infections requiring hospitalization | 7.67% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 99 · Observed rate 7.07% · Lower 95% interval 4.37% |
| Staff COVID-19 vaccination coverage | 2.7% |
8.2%
5.5 pts worse
|
Numerator 5 · Denominator 185 |
| Staff flu vaccination coverage | 78% |
42%
36 pts better
|
Numerator 156 · Denominator 200 |
| Discharge function score | 87.76% |
56.45%
31.3 pts better
|
Numerator 86 · Denominator 98 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 98.46% |
96.28%
2.2 pts better
|
Numerator 64 · Denominator 65 |
| Resident COVID-19 vaccinations up to date | 37.93% |
25.2%
12.7 pts better
|
Numerator 22 · Denominator 58 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.7
0.3 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.6 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.5 |
2.0
2.5 pts worse
|
1.8
2.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.5 · Observed 4.8 · Expected 1.8 · 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 | 97.0% |
96.1%
0.9 pts better
|
95.5%
1.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.8% |
3.9%
1.9 pts worse
|
3.3%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 9.4% · Q3 4.6% · Q4 5.8% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
4.3%
3.5 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 4.6% |
4.1%
0.5 pts worse
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 9.3% · Q3 1.8% · Q4 0.0% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.0% |
12.4%
2.6 pts worse
|
19.6%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 12.7% · Q3 14.3% · Q4 16.1% · 4Q avg 15.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.2% |
17.5%
6.3 pts better
|
16.7%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 9.3% · Q3 4.4% · Q4 17.0% · 4Q avg 11.2% · 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 | 29.8% |
22.5%
7.3 pts worse
|
16.3%
13.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 14.8% · Q3 36.8% · Q4 43.3% · 4Q avg 29.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.5% |
18.6%
7.9 pts worse
|
14.9%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 20.0% · Q3 44.0% · Q4 28.8% · 4Q avg 26.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
2.3%
2 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% · 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 0.0% · Q2 1.6% · Q3 1.6% · Q4 1.4% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.3% |
24.8%
4.5 pts worse
|
19.8%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 25.1% · Q3 39.4% · Q4 25.5% · 4Q avg 29.3% |
| Percentage of long-stay residents with pressure ulcers | 8.4% |
5.4%
3 pts worse
|
5.1%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 7.8% · Q3 8.8% · Q4 8.8% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.1% |
88.6%
0.5 pts worse
|
81.7%
6.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 84.3% · Q2 84.3% · Q3 95.0% · Q4 90.9% · 4Q avg 88.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.0% |
14.0%
3 pts worse
|
12.0%
5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.0% · Observed 17.6% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.9%
0.8 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 70.0% |
82.7%
12.7 pts worse
|
79.7%
9.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 70.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 10.7% |
23.1%
12.4 pts better
|
23.9%
13.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.7% · Observed 8.2% · Expected 18.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-30 · Fire 2024-10-30
3 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-11-30 · Fire 2023-11-30
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-12-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-10
E · Potential for more than minimal harm
2024-10-30
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 2024-11-25
D · Potential for more than minimal harm
2024-10-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-25
D · Potential for more than minimal harm
2023-11-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-01-10
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-03
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2026-01-06
F · Potential for more than minimal harm
2025-12-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-06
F · Potential for more than minimal harm
2025-12-03
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 2026-01-06
J · Immediate jeopardy
2025-09-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-21
F · Potential for more than minimal harm
2024-10-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-25
E · Potential for more than minimal harm
2024-10-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-25
D · Potential for more than minimal harm
2024-10-30
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-11-25
G · Actual harm
2023-11-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-04
F · Potential for more than minimal harm
2023-11-30
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-11-30
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 2024-01-04
E · Potential for more than minimal harm
2023-11-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-11-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-11-30
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-11-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-11-30
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-11-30
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-01-04
Penalties and ownership
What sits behind the stars
$0
2023-11-30
Payment Denial
Payment Denial · denial start 2024-01-04 · 6 days
6 day denial
Ownership
Avera Health
5% Or Greater Direct Ownership Interest · Organization
Avera Health
Operational/Managerial Control · Organization
Beckfield, Michael
Corporate Officer · Individual
Coudron, Christy
Corporate Officer · Individual
Crim, Stephen
Corporate Director · Individual
Dover, James
Corporate Officer · Individual
Fixen, Quentin
Corporate Director · Individual
Goepferich, Gregory
Corporate Director · Individual
Hennen, Sharon
Corporate Director · Individual
Johansen, Laurie
Corporate Director · Individual
Jorgenson, George
Corporate Director · Individual
Koenen, Lavonne
Corporate Director · Individual
Lautt, Julie
Corporate Officer · Individual
Louwagie, Curtis
Corporate Director · Individual
O'leary, Tim
Corporate Director · Individual
Sieling, Amanda
Corporate Director · Individual
Streier, Debra
Corporate Officer · Individual
Strootman, Joyce
Corporate Director · Individual
Vortherms, Mark
Corporate Officer · Individual
Vortherms, Mark
W-2 Managing Employee · Individual
Vroman, Jill
Corporate Director · Individual
Walker, Victoria
Corporate Officer · Individual
Zimmerman, Jodelle
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Prairie View Senior Living
Tracy, MN
2-star overall rating with 2-star inspections with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Avera Sunrise Manor
Tyler, MN
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Clarkfield Care Center
Clarkfield, MN
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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