Cycle 1
Health 2025-02-20 · Fire 2025-02-20
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Belgrade, MN
Belgrade Nursing Home
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
103 School Street, Belgrade, MN
(320) 254-8215
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
34
Certified beds
Average residents
22
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1987-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.84
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
1.18
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
3.09
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
5.10
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
2.02
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.49
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.78
CMS adjusted RN staffing hours
Adjusted total hours
4.76
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,761
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.14
Composite VBP score used to determine payment impact.
Payment multiplier
1.0090
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
4.79
Baseline 54.05% · Performance 44.12% · Measure score 4.79 · Achievement 4.79 · Improvement 2.90
Adjusted total nurse staffing
6.04
Baseline 4.40 hours · Performance 4.80 hours · Measure score 6.04 · Achievement 6.04 · Improvement 2.36
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 14 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 6 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 8.77% |
8.2%
0.6 pts better
|
Numerator 5 · Denominator 57 |
| Staff flu vaccination coverage | 18.03% |
42%
24 pts worse
|
Numerator 11 · Denominator 61 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.6% |
3.9%
1.7 pts worse
|
3.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 9.1% · Q3 4.8% · Q4 4.5% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.9% |
4.3%
0.6 pts worse
|
11.4%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 5.0% · Q3 0.0% · 4Q avg 4.9% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
4.1%
0.6 pts worse
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 4.5% · Q4 5.0% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.1% |
12.4%
3.7 pts worse
|
19.6%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 13.6% · Q3 15.0% · Q4 14.3% · 4Q avg 16.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.5% |
17.5%
3 pts better
|
16.7%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 15.0% · 4Q avg 14.5% · 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 | 18.4% |
22.5%
4.1 pts better
|
16.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.5% |
18.6%
0.9 pts worse
|
14.9%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 19.0% · 4Q avg 19.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.3%
2.3 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.7% |
2.6%
3.1 pts worse
|
1.7%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 9.1% · Q3 5.0% · Q4 4.8% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.8% |
24.8%
1 pts better
|
19.8%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.6% · Q2 30.5% · Q4 18.1% · 4Q avg 23.8% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
5.4%
3.4 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q3 4.5% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.2% |
88.6%
4.6 pts better
|
81.7%
11.5 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 93.2% |
| 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 · 4Q avg 0.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-21 · Fire 2023-12-21
2 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-11-03 · Fire 2022-11-03
2 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-31
F · Potential for more than minimal harm
2025-02-20
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-03-31
F · Potential for more than minimal harm
2025-02-20
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 2025-03-31
F · Potential for more than minimal harm
2025-02-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-20
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-20
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-20
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-31
D · Potential for more than minimal harm
2023-12-21
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 2024-01-11
F · Potential for more than minimal harm
2022-11-03
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-12-15
F · Potential for more than minimal harm
2022-11-03
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-11-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-13
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-08-12
D · Potential for more than minimal harm
2025-06-13
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 2025-07-25
F · Potential for more than minimal harm
2025-02-20
F838 · Administration Deficiencies
Health
Conduct 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.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-20
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-20
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 2025-03-31
F · Potential for more than minimal harm
2023-12-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-17
D · Potential for more than minimal harm
2023-12-21
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 2024-01-17
F · Potential for more than minimal harm
2022-11-03
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2022-11-30
F · Potential for more than minimal harm
2022-11-03
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 2022-12-14
Penalties and ownership
What sits behind the stars
Ownership
Fischer, Stephanie
Operational/Managerial Control · Individual
Lemmer, James
Corporate Director · Individual
Lieser, Trudy
Corporate Director · Individual
Montenegro, Robert
Contracted Managing Employee · Individual
Westaby, Sandra
Corporate Director · Individual
Winger, Ann
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Glenoaks Senior Living Campus
New London, MN
1-star overall rating with 1-star inspections with $43,219 in total fines with 18 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Paynesville Health Care Center
Paynesville, MN
5-star overall rating with 5-star inspections with 1 recent health deficiencies
#3
Cura Of Melrose
Melrose, MN
2-star overall rating with 2-star inspections with 12 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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