Cycle 1
Health 2025-07-24 · Fire 2025-07-24
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
North Branch, MN
Ecumen North Branch
3-star overall rating with 3-star inspections with 3 recent health deficiencies
5379 -383rd Street, North Branch, MN
(651) 829-0117
Overall
3 / 5
CMS overall stars
Health inspections
3 / 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
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
1986-12-01
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
1.09
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.57
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.52
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.94
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.95
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.70
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.21
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.17
CMS adjusted RN staffing hours
Adjusted total hours
4.86
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
68%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,286
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.19
Composite VBP score used to determine payment impact.
Payment multiplier
0.9858
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.80
Performance 21.06% · Measure score 0.80 · Achievement 0.80 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
4.12
Performance 6.60% · Measure score 4.12 · Achievement 4.12 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
2.10
Baseline 61.54% · Performance 55.10% · Measure score 2.10 · Achievement 2.10 · Improvement 1.25
Adjusted total nurse staffing
5.06
Baseline 4.04 hours · Performance 4.52 hours · Measure score 5.06 · Achievement 5.06 · Improvement 2.23
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.49% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 59 · Observed rate 5.08% · Lower 95% interval 6.21% |
| Discharge to community | 51.29% |
50.57%
0.7 pts better
|
No Different than the National Rate · Eligible stays 64 · Observed rate 46.88% · Lower 95% interval 42% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 46 · Denominator 46 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 46 |
| Discharge self-care score | 66.67% |
53.69%
13 pts better
|
Numerator 26 · Denominator 39 |
| Discharge mobility score | 71.79% |
50.94%
20.9 pts better
|
Numerator 28 · Denominator 39 |
| Pressure ulcers or injuries, new or worsened | 6.52% |
2.29%
4.2 pts worse
|
Numerator 3 · Denominator 46 · Adjusted rate 10.24% |
| Healthcare-associated infections requiring hospitalization | 6.6% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 44 · Observed rate 4.55% · Lower 95% interval 3.87% |
| Staff COVID-19 vaccination coverage | 0.91% |
8.2%
7.3 pts worse
|
Numerator 1 · Denominator 110 |
| Staff flu vaccination coverage | 19.4% |
42%
22.6 pts worse
|
Numerator 26 · Denominator 134 |
| Discharge function score | 79.49% |
56.45%
23 pts better
|
Numerator 31 · Denominator 39 |
| Transfer of health information to provider | 96.67% |
95.95%
0.7 pts better
|
Numerator 29 · Denominator 30 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 53.85% |
25.2%
28.7 pts better
|
Numerator 14 · Denominator 26 |
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 | 95.1% |
96.1%
1 pts worse
|
95.5%
0.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.0% |
3.9%
3.1 pts worse
|
3.3%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 8.3% · Q3 7.5% · Q4 6.1% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.2% |
4.3%
0.9 pts worse
|
11.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 5.9% · Q3 8.1% · Q4 3.3% · 4Q avg 5.2% |
| 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 0.0% · Q3 7.1% · Q4 4.8% · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 0.0% |
12.4%
12.4 pts better
|
19.6%
19.6 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 who received an antipsychotic medication | 5.4% |
17.5%
12.1 pts better
|
16.7%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 9.5% · Q3 4.8% · 4Q avg 5.4% · 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 | 34.7% |
22.5%
12.2 pts worse
|
16.3%
18.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 34.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.4% |
18.6%
5.8 pts worse
|
14.9%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 17.4% · Q3 30.8% · 4Q avg 24.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.9% |
2.3%
1.6 pts worse
|
1.0%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 2.1% · Q3 4.6% · Q4 0.0% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
2.6%
0.5 pts better
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.8% · Q3 2.5% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.2% |
24.8%
5.4 pts worse
|
19.8%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.9% · Q2 38.5% · Q3 28.1% · Q4 29.0% · 4Q avg 30.2% |
| Percentage of long-stay residents with pressure ulcers | 15.6% |
5.4%
10.2 pts worse
|
5.1%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 18.2% · Q3 13.3% · Q4 6.6% · 4Q avg 15.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
88.6%
8.3 pts better
|
81.7%
15.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 97.3% · Q3 97.5% · Q4 95.9% · 4Q avg 96.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.1% |
14.0%
5.1 pts worse
|
12.0%
7.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.1% · Observed 18.2% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
1.9%
0.4 pts worse
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 3.8% · Q4 3.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.9% |
82.7%
8.2 pts better
|
79.7%
11.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.3% |
23.1%
7.2 pts worse
|
23.9%
6.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.3% · Observed 25.0% · Expected 19.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-09 · Fire 2024-08-09
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-09-27 · Fire 2023-09-27
3 health deficiencies
Top issue: Infection Control (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-16
F · Potential for more than minimal harm
2024-08-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-08-29
E · Potential for more than minimal harm
2024-08-09
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 2024-08-29
F · Potential for more than minimal harm
2023-09-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-13
E · Potential for more than minimal harm
2023-09-27
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-11-13
E · Potential for more than minimal harm
2023-09-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-13
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-07-24
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 2025-08-28
F · Potential for more than minimal harm
2025-07-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-20
C · Minimal harm
2025-07-24
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-08-19
F · Potential for more than minimal harm
2024-08-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-08-09
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-08-09
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-08-09
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-08-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-08-09
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-08-09
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 2024-08-29
D · Potential for more than minimal harm
2024-06-17
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-07-10
E · Potential for more than minimal harm
2023-09-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-13
D · Potential for more than minimal harm
2023-09-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-13
D · Potential for more than minimal harm
2023-09-27
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-11-13
Penalties and ownership
What sits behind the stars
Ownership
Bjerketvedt, Scott
Operational/Managerial Control · Individual
Bjerketvedt, Scott
Corporate Officer · Individual
Bjerketvedt, Scott
W-2 Managing Employee · Individual
Crockett, Susan
Corporate Director · Individual
Dady, James
Corporate Director · Individual
Ecumen
5% Or Greater Direct Ownership Interest · Organization
Kendrick, Shelley
Operational/Managerial Control · Individual
Kendrick, Shelley
Corporate Director · Individual
Petraborg, John
Corporate Director · Individual
Ulvestad, Nancy
Corporate Director · Individual
Nearby options
Other facilities in reach
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Parmly on the Lake LLC
Chisago City, MN
3-star overall rating with 3-star inspections with $8,193 in total fines with 7 recent health deficiencies
#2
The Estates at Rush City LLC
Rush City, MN
3-star overall rating with 3-star inspections with 7 recent health deficiencies
#3
Meadows On Fairview
Wyoming, MN
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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