Cycle 1
Health 2025-03-27 · Fire 2025-03-27
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Golden Valley, MN
Courage Kenny Rehabilitation Institutes Trp
5-star overall rating with 4-star inspections with 2 recent health deficiencies
3915 Golden Valley Road, Golden Valley, MN
(612) 775-2835
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
56
Certified beds
Average residents
41
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1988-02-01
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
2.96
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.09
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
4.50
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
7.55
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
3.05
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
6.93
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
2.66
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.86
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
2.95
CMS adjusted RN staffing hours
Adjusted total hours
7.53
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
25%
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
1,030
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
60.92
Composite VBP score used to determine payment impact.
Payment multiplier
1.0160
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
2.08
Baseline 6.29% · Performance 7.21% · Measure score 2.08 · Achievement 2.08 · Improvement 0
Total nurse turnover
6.19
Baseline 43.69% · Performance 38.37% · Measure score 6.19 · Achievement 6.19 · Improvement 2.32
Adjusted total nurse staffing
10
Baseline 6.48 hours · Performance 8.08 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.28% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 5.71% · Lower 95% interval 5.96% |
| Discharge to community | 51.96% |
50.57%
1.4 pts better
|
No Different than the National Rate · Eligible stays 37 · Observed rate 43.24% · Lower 95% interval 38.34% |
| Medicare spending per beneficiary | 1.32 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 36 · Denominator 36 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 36 |
| Discharge self-care score | 73.33% |
53.69%
19.6 pts better
|
Numerator 22 · Denominator 30 |
| Discharge mobility score | 70% |
50.94%
19.1 pts better
|
Numerator 21 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 5.56% |
2.29%
3.3 pts worse
|
Numerator 2 · Denominator 36 · Adjusted rate 6.6% |
| Healthcare-associated infections requiring hospitalization | 7.21% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 25 · Observed rate 8% · Lower 95% interval 3.42% |
| Staff COVID-19 vaccination coverage | 18.72% |
8.2%
10.5 pts better
|
Numerator 44 · Denominator 235 |
| Staff flu vaccination coverage | 76.56% |
42%
34.6 pts better
|
Numerator 196 · Denominator 256 |
| Discharge function score | 80% |
56.45%
23.5 pts better
|
Numerator 24 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 20 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · 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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.9%
3.9 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.5% |
4.3%
2.2 pts worse
|
11.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.5% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
4.1%
1.8 pts worse
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.8% |
12.4%
3.6 pts better
|
19.6%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
17.5%
17.5 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.3% |
18.6%
10.3 pts better
|
14.9%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
2.6%
0.3 pts worse
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.0% |
24.8%
12.8 pts better
|
19.8%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.0% |
| Percentage of long-stay residents with pressure ulcers | 19.9% |
5.4%
14.5 pts worse
|
5.1%
14.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
88.6%
8.8 pts better
|
81.7%
15.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.2% · Q2 97.7% · Q3 97.8% · Q4 98.6% · 4Q avg 97.4% |
| 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 1.1% · Q2 1.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.5% |
82.7%
12.8 pts better
|
79.7%
15.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-14 · Fire 2023-12-14
3 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-03-30 · Fire 2023-03-30
1 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-12-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-01-19
C · Minimal harm
2023-12-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-01-19
C · Minimal harm
2023-12-14
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2024-01-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-01-12
D · Potential for more than minimal harm
2025-05-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-01
F · Potential for more than minimal harm
2023-12-14
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 2024-01-19
D · Potential for more than minimal harm
2023-12-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-19
C · Minimal harm
2023-12-14
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-01-19
C · Minimal harm
2023-12-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-19
Penalties and ownership
What sits behind the stars
Ownership
Allina Health System
5% Or Greater Direct Ownership Interest · Organization
Allina Health System
Operational/Managerial Control · Organization
Alstad, Jennifer
Corporate Director · Individual
Baker, Chanda
Corporate Director · Individual
Ballard, Shari
Corporate Director · Individual
Borgstrom, Marna
Corporate Director · Individual
Church, John
Corporate Director · Individual
Estes, Melinda
Corporate Director · Individual
Gillund, Laura
Corporate Director · Individual
Hang, Maykao
Corporate Director · Individual
Joos, David
Operational/Managerial Control · Individual
Joos, David
Corporate Officer · Individual
King, Louis
Corporate Director · Individual
Kolar, James
Corporate Director · Individual
Kuplic, David
Corporate Director · Individual
Lindig, Marcia
Operational/Managerial Control · Individual
Lowe, Challis
Corporate Director · Individual
Mcgrane, Brian
Corporate Director · Individual
Newcome, Roger
Corporate Director · Individual
O'laughlin, Daniel
Corporate Director · Individual
Rasmusen, Vicki
Corporate Director · Individual
Ronneberg, Amy
Corporate Director · Individual
Schirmers, Patricia
Operational/Managerial Control · Individual
Schirmers, Patricia
Corporate Director · Individual
Schoneman, Debbra
Corporate Director · Individual
Schreier, Thomas
Corporate Director · Individual
Shannon, Lisa
Corporate Director · Individual
Street, Heidi
Operational/Managerial Control · Individual
Tallarico, Dominica
Corporate Officer · Individual
Tukua, Darrell
Corporate Director · Individual
Ulreich, Shawn
Corporate Director · Individual
Welsh, Timothy
Corporate Director · Individual
Williams, Barbara
Corporate Director · Individual
Williams-Brinkley, Ruth
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
The Villas At Robbinsdale
Robbinsdale, MN
2-star overall rating with 2-star inspections with $32,122 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Covenant Living Of Golden Valley Care & Rehab Ctr
Golden Valley, MN
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
The Villas At Bryn Mawr LLC
Minneapolis, MN
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $35,260 in total fines with 23 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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