Cycle 1
Health 2025-01-23 · Fire 2025-01-23
2 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Sartell, MN
Country Manor Health & Rehab Ctr
5-star overall rating with 4-star inspections with 2 recent health deficiencies
520 First Street Northeast, Sartell, MN
(320) 253-1920
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
131
Certified beds
Average residents
122
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1986-07-01
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
0.79
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
3.46
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
5.21
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.75
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
0.39
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.22
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.84
CMS adjusted RN staffing hours
Adjusted total hours
5.58
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,403
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.94
Composite VBP score used to determine payment impact.
Payment multiplier
1.0040
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.25
Baseline 23.05% · Performance 22.00% · Measure score 1.25 · Achievement 0 · Improvement 1.25
Healthcare-associated infections
3.36
Baseline 5.71% · Performance 6.83% · Measure score 3.36 · Achievement 3.36 · Improvement 0
Total nurse turnover
6.20
Baseline 42.58% · Performance 38.33% · Measure score 6.20 · Achievement 6.20 · Improvement 1.90
Adjusted total nurse staffing
9.17
Baseline 4.75 hours · Performance 5.69 hours · Measure score 9.17 · Achievement 9.17 · Improvement 8.58
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.47% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 268 · Observed rate 7.46% · Lower 95% interval 6.93% |
| Discharge to community | 63.32% |
50.57%
12.8 pts better
|
Better than the National Rate · Eligible stays 271 · Observed rate 63.1% · Lower 95% interval 57.91% |
| Medicare spending per beneficiary | 0.78 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96.63% |
95.27%
1.4 pts better
|
Numerator 172 · Denominator 178 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 178 |
| Discharge self-care score | 75.18% |
53.69%
21.5 pts better
|
Numerator 103 · Denominator 137 |
| Discharge mobility score | 78.1% |
50.94%
27.2 pts better
|
Numerator 107 · Denominator 137 |
| Pressure ulcers or injuries, new or worsened | 1.12% |
2.29%
1.2 pts better
|
Numerator 2 · Denominator 178 · Adjusted rate 1.33% |
| Healthcare-associated infections requiring hospitalization | 6.83% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 159 · Observed rate 5.03% · Lower 95% interval 4.55% |
| Staff COVID-19 vaccination coverage | 11.78% |
8.2%
3.6 pts better
|
Numerator 41 · Denominator 348 |
| Staff flu vaccination coverage | 25.7% |
42%
16.3 pts worse
|
Numerator 119 · Denominator 463 |
| Discharge function score | 76.64% |
56.45%
20.2 pts better
|
Numerator 105 · Denominator 137 |
| Transfer of health information to provider | 98.39% |
95.95%
2.4 pts better
|
Numerator 122 · Denominator 124 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 29 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 59.14% |
25.2%
33.9 pts better
|
Numerator 55 · Denominator 93 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.7
0.6 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.5 · 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 0.9 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
97.3%
0.2 pts worse
|
93.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 96.4% · Q3 95.3% · Q4 97.6% · 4Q avg 97.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.8% |
96.1%
1.7 pts better
|
95.5%
2.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
3.9%
1.8 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 2.4% · Q4 4.8% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.5% |
4.3%
0.8 pts better
|
11.4%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 2.6% · Q3 3.7% · Q4 3.9% · 4Q avg 3.5% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
4.1%
1.2 pts worse
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 6.8% · Q3 5.6% · Q4 4.7% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.8% |
12.4%
7.4 pts worse
|
19.6%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 21.6% · Q3 19.2% · Q4 17.9% · 4Q avg 19.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.1% |
17.5%
4.4 pts better
|
16.7%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 13.6% · Q3 12.3% · Q4 16.7% · 4Q avg 13.1% · 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 | 32.7% |
22.5%
10.2 pts worse
|
16.3%
16.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.1% · Q2 42.3% · Q3 27.2% · 4Q avg 32.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 30.9% |
18.6%
12.3 pts worse
|
14.9%
16 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 32.9% · Q3 29.2% · Q4 35.6% · 4Q avg 30.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.4% |
2.3%
2.1 pts worse
|
1.0%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 3.9% · Q3 3.6% · Q4 3.0% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.7% |
2.6%
0.1 pts worse
|
1.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 1.2% · Q3 2.4% · Q4 2.5% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.6% |
24.8%
2.8 pts worse
|
19.8%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.4% · Q2 21.2% · Q3 18.8% · Q4 30.1% · 4Q avg 27.6% |
| Percentage of long-stay residents with pressure ulcers | 7.6% |
5.4%
2.2 pts worse
|
5.1%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 8.1% · Q3 8.5% · Q4 6.4% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.9% |
88.6%
2.7 pts worse
|
81.7%
4.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.3% · Q2 89.2% · Q3 84.4% · Q4 82.3% · 4Q avg 85.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.4% |
14.0%
6.6 pts better
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 6.1% · Expected 9.3% · 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 0.0% · Q2 0.4% · Q3 0.5% · Q4 2.2% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.8% |
82.7%
14.1 pts better
|
79.7%
17.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.0% |
23.1%
5.1 pts better
|
23.9%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 13.4% · Expected 17.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-30 · Fire 2023-11-30
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2022-10-12 · Fire 2022-10-12
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-11-30
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-01-03
F · Potential for more than minimal harm
2023-11-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-29
D · Potential for more than minimal harm
2022-10-12
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-11-03
C · Minimal harm
2022-10-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-03
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-01-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-01-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-04
D · Potential for more than minimal harm
2023-11-30
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-11-30
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-01-03
Penalties and ownership
What sits behind the stars
Ownership
Foundation For Health Care Continuums
5% Or Greater Direct Ownership Interest · Organization
Brown, Fred
Corporate Director · Individual
Continuums Management Services LLC
Operational/Managerial Control · Organization
Fenstad, Anthony
Operational/Managerial Control · Individual
Fenstad, Anthony
Corporate Officer · Individual
Fraraccio, Felix
Corporate Director · Individual
Harguth, Kevin
Operational/Managerial Control · Individual
Harguth, Kevin
Corporate Officer · Individual
Rosen, Michael
Operational/Managerial Control · Individual
Rosen, Michael
Corporate Director · Individual
Sanders, Paul
Corporate Director · Individual
Wheaton, Sherry
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Good Shepherd Lutheran Home
Sauk Rapids, MN
5-star overall rating with 3-star inspections with $10,000 in total fines with 9 recent health deficiencies with 2 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
Edenbrook of St Cloud
Saint Cloud, MN
3-star overall rating with 3-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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