Cycle 1
Health 2025-03-04 · Fire 2025-03-04
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Sleepy Eye, MN
Divine Providence Community Home
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
700 Third Avenue Northwest, Sleepy Eye, MN
(507) 794-3011
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
44
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1991-10-01
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
0.77
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.42
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
3.81
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.39
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.34
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.89
CMS adjusted RN staffing hours
Adjusted total hours
4.40
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
18%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,352
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
57.36
Composite VBP score used to determine payment impact.
Payment multiplier
1.0125
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
7.25
Baseline 35.71% · Performance 34.04% · Measure score 7.25 · Achievement 7.25 · Improvement 1.04
Adjusted total nurse staffing
4.22
Baseline 4.21 hours · Performance 4.28 hours · Measure score 4.22 · Achievement 4.22 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.03% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 3.13% · Lower 95% interval 6.2% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 96.55% |
95.27%
1.3 pts better
|
Numerator 28 · Denominator 29 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 29 |
| Discharge self-care score | 37.04% |
53.69%
16.6 pts worse
|
Numerator 10 · Denominator 27 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 9 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 10.34% |
2.29%
8.1 pts worse
|
Numerator 3 · Denominator 29 · Adjusted rate 14.1% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 6.38% |
8.2%
1.8 pts worse
|
Numerator 6 · Denominator 94 |
| Staff flu vaccination coverage | 28.97% |
42%
13 pts worse
|
Numerator 31 · Denominator 107 |
| Discharge function score | 62.96% |
56.45%
6.5 pts better
|
Numerator 17 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.7
0.2 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.5 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.0 |
2.0
2 pts worse
|
1.8
2.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.0 · Observed 3.3 · Expected 1.4 · 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 | 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 | 6.0% |
3.9%
2.1 pts worse
|
3.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 7.9% · Q3 2.4% · Q4 2.3% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.0% |
4.3%
0.7 pts worse
|
11.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 5.4% · Q3 2.5% · Q4 2.6% · 4Q avg 5.0% |
| Percentage of long-stay residents who lose too much weight | 4.5% |
4.1%
0.4 pts worse
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.7% · Q3 12.5% · Q4 2.4% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.3% |
12.4%
9.9 pts worse
|
19.6%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 23.7% · Q3 22.0% · Q4 24.4% · 4Q avg 22.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.3% |
17.5%
5.2 pts better
|
16.7%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 11.8% · Q3 13.9% · Q4 16.7% · 4Q avg 12.3% · 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 | 25.0% |
22.5%
2.5 pts worse
|
16.3%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 9.1% · Q3 26.9% · Q4 34.9% · 4Q avg 25.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.1% |
18.6%
0.5 pts worse
|
14.9%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 13.9% · Q3 15.0% · Q4 25.0% · 4Q avg 19.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 7.2% |
2.3%
4.9 pts worse
|
1.0%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 8.1% · Q3 7.6% · Q4 6.2% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 10.4% |
2.6%
7.8 pts worse
|
1.7%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 16.2% · Q3 12.2% · Q4 11.6% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.2% |
24.8%
3.6 pts better
|
19.8%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 17.4% · Q3 19.9% · Q4 26.9% · 4Q avg 21.2% |
| Percentage of long-stay residents with pressure ulcers | 8.0% |
5.4%
2.6 pts worse
|
5.1%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 6.9% · Q3 5.8% · Q4 4.4% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
88.6%
11.4 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 24.4% |
14.0%
10.4 pts worse
|
12.0%
12.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.4% · Observed 20.0% · Expected 9.2% · Used in QM five-star |
| 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 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.5% |
82.7%
10.8 pts better
|
79.7%
13.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 11.5% |
23.1%
11.6 pts better
|
23.9%
12.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.5% · Observed 8.0% · Expected 16.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-14 · Fire 2024-02-14
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-11-09 · Fire 2022-11-09
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-04
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-03-31
E · Potential for more than minimal harm
2025-03-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-03-04
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-03-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-30
E · Potential for more than minimal harm
2022-11-09
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-12-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-04
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 2025-03-31
D · Potential for more than minimal harm
2025-03-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-31
G · Actual harm
2024-05-10
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 2024-06-07
E · Potential for more than minimal harm
2024-02-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-14
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-14
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 2024-03-29
G · Actual harm
2022-11-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-12-29
F · Potential for more than minimal harm
2022-11-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-26
E · Potential for more than minimal harm
2022-11-09
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 2022-12-15
D · Potential for more than minimal harm
2022-11-09
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-11-09
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 2022-12-29
D · Potential for more than minimal harm
2022-11-09
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 2022-12-29
D · Potential for more than minimal harm
2022-11-09
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-12-29
C · Minimal harm
2022-11-09
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-12-15
Penalties and ownership
What sits behind the stars
Ownership
Butler, Rita
Corporate Officer · Individual
Groebner, Jayna
Operational/Managerial Control · Individual
Haas, Caryn
Corporate Director · Individual
Hubler, Margaret
Corporate Director · Individual
Kosman, Janet
Corporate Officer · Individual
Murthy, Venkata
Operational/Managerial Control · Individual
Williams, Sharon
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Sleepy Eye Rehabilitati Center
Sleepy Eye, MN
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Gil-Mor Manor
Morgan, MN
2-star overall rating with 2-star inspections with 13 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Oak Hills Living Center
New Ulm, MN
3-star overall rating with 2-star inspections with $38,219 in total fines with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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