Cycle 1
Health 2024-10-30 · Fire 2024-10-30
6 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
St Peter, MN
Benedictine Living Community Of St. Peter
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1907 Klein Street, St Peter, MN
(507) 934-2203
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
79
Certified beds
Average residents
69
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Benedictine Health System
Operator or chain grouping
Approved since
1987-11-01
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.95
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.51
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.56
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
1.45
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.46
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.52
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
1.03
CMS adjusted RN staffing hours
Adjusted total hours
4.36
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,756
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.95
Composite VBP score used to determine payment impact.
Payment multiplier
1.0016
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.86
Baseline 17.28% · Performance 18.71% · Measure score 5.86 · Achievement 5.86 · Improvement 0
Healthcare-associated infections
8.01
Baseline 5.49% · Performance 5.44% · Measure score 8.01 · Achievement 8.01 · Improvement 0.38
Total nurse turnover
1.68
Baseline 79.76% · Performance 67.82% · Measure score 1.68 · Achievement 0 · Improvement 1.68
Adjusted total nurse staffing
3.63
Baseline 3.97 hours · Performance 4.11 hours · Measure score 3.63 · Achievement 3.63 · Improvement 0.28
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.34% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 128 · Observed rate 8.59% · Lower 95% interval 7.23% |
| Discharge to community | 54.92% |
50.57%
4.4 pts better
|
No Different than the National Rate · Eligible stays 119 · Observed rate 52.94% · Lower 95% interval 47.12% |
| Medicare spending per beneficiary | 0.66 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 150 · Denominator 150 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 150 |
| Discharge self-care score | 43.31% |
53.69%
10.4 pts worse
|
Numerator 55 · Denominator 127 |
| Discharge mobility score | 32.28% |
50.94%
18.7 pts worse
|
Numerator 41 · Denominator 127 |
| Pressure ulcers or injuries, new or worsened | 4% |
2.29%
1.7 pts worse
|
Numerator 6 · Denominator 150 · Adjusted rate 4.61% |
| Healthcare-associated infections requiring hospitalization | 5.44% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 86 · Observed rate 1.16% · Lower 95% interval 2.85% |
| Staff COVID-19 vaccination coverage | 1.68% |
8.2%
6.5 pts worse
|
Numerator 3 · Denominator 179 |
| Staff flu vaccination coverage | 19.14% |
42%
22.9 pts worse
|
Numerator 62 · Denominator 324 |
| Discharge function score | 55.91% |
56.45%
0.5 pts worse
|
Numerator 71 · Denominator 127 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 98.84% |
96.28%
2.6 pts better
|
Numerator 85 · Denominator 86 |
| Resident COVID-19 vaccinations up to date | 51.39% |
25.2%
26.2 pts better
|
Numerator 37 · Denominator 72 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.7
0.9 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.9 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.1 |
2.0
1.1 pts worse
|
1.8
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 3.6 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
97.3%
1.4 pts better
|
93.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.2% · Q2 98.2% · Q3 100.0% · Q4 100.0% · 4Q avg 98.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.8% |
96.1%
0.7 pts better
|
95.5%
1.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
3.9%
About the same
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 3.5% · Q3 5.0% · Q4 4.8% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.5% |
4.3%
2.8 pts better
|
11.4%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.1% · Q4 4.0% · 4Q avg 1.5% |
| Percentage of long-stay residents who lose too much weight | 2.9% |
4.1%
1.2 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.5% · Q3 3.7% · Q4 1.8% · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 51.7% |
12.4%
39.3 pts worse
|
19.6%
32.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.4% · Q2 58.2% · Q3 57.4% · Q4 45.5% · 4Q avg 51.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 31.4% |
17.5%
13.9 pts worse
|
16.7%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.7% · Q2 39.1% · Q3 31.8% · Q4 22.7% · 4Q avg 31.4% · 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 | 15.1% |
22.5%
7.4 pts better
|
16.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 16.1% · Q4 11.2% · 4Q avg 15.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.9% |
18.6%
4.3 pts worse
|
14.9%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 31.9% · Q3 30.4% · Q4 10.2% · 4Q avg 22.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
2.3%
0.7 pts better
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.3% · Q3 1.0% · Q4 1.2% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
2.6%
0.4 pts better
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 5.0% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.7% |
24.8%
4.9 pts worse
|
19.8%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.4% · Q2 31.0% · Q3 22.5% · Q4 32.8% · 4Q avg 29.7% |
| Percentage of long-stay residents with pressure ulcers | 8.9% |
5.4%
3.5 pts worse
|
5.1%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 9.9% · Q3 8.1% · Q4 7.5% · 4Q avg 8.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.7% |
88.6%
6.1 pts better
|
81.7%
13 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.0% · Q2 95.3% · Q3 96.4% · Q4 91.0% · 4Q avg 94.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 25.3% |
14.0%
11.3 pts worse
|
12.0%
13.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.3% · Observed 22.8% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.9%
0.6 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 1.2% · Q4 2.5% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.8% |
82.7%
0.9 pts worse
|
79.7%
2.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.5% |
23.1%
0.4 pts worse
|
23.9%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.5% · Observed 17.4% · Expected 17.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-20 · Fire 2023-12-20
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2023-01-26 · Fire 2023-01-26
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-30
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-12-16
D · 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 2024-11-27
C · Minimal harm
2024-10-30
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-11-27
F · Potential for more than minimal harm
2023-12-20
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-01-11
F · Potential for more than minimal harm
2023-12-20
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-02-29
F · Potential for more than minimal harm
2023-12-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-01-02
F · Potential for more than minimal harm
2023-12-20
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-01-02
F · Potential for more than minimal harm
2023-12-20
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 2024-02-05
F · Potential for more than minimal harm
2023-12-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-12-20
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-01-02
D · Potential for more than minimal harm
2023-12-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-01-12
C · Minimal harm
2023-12-20
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-12-27
C · Minimal harm
2023-12-20
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-12-27
F · Potential for more than minimal harm
2023-01-26
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-03-10
F · Potential for more than minimal harm
2023-01-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-10
F · Potential for more than minimal harm
2023-01-26
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-03-10
F · Potential for more than minimal harm
2023-01-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-01-26
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-10-30
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-10-30
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-10-30
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-10-30
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 2024-12-16
D · Potential for more than minimal harm
2024-10-30
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-10-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-02-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-07
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-03-01
F · Potential for more than minimal harm
2023-12-20
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-02-09
E · Potential for more than minimal harm
2023-12-20
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 2024-02-09
D · Potential for more than minimal harm
2023-12-20
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 2024-02-09
D · Potential for more than minimal harm
2023-12-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-09
F · Potential for more than minimal harm
2023-01-26
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 2023-03-17
D · Potential for more than minimal harm
2023-01-26
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-01-26
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 2023-03-17
D · Potential for more than minimal harm
2023-01-26
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-01-26
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-01-26
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-03-17
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
Bray, Alan
Corporate Director · Individual
Bruhn, Jennifer
Corporate Director · Individual
Carley, Gerald
Operational/Managerial Control · Individual
Hildebrandt, Teresa
Contracted Managing Employee · Individual
Holland, Kristen
Corporate Director · Individual
Minter, Douglas
Corporate Director · Individual
Rundell, Marilyn
Corporate Director · Individual
Rymanowski, Kevin
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Cura Of Le Sueur
Le Sueur, MN
1-star overall rating with 2-star inspections with $12,340 in total fines with 16 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Central Health Care Center
Le Center, MN
3-star overall rating with 2-star inspections with $21,048 in total fines with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Oaklawn Care & Rehabilitation Center
Mankato, MN
2-star overall rating with 2-star inspections with $59,001 in total fines with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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