Pine Island, MN

Edenbrook Pine Haven

3-star overall rating with 3-star inspections with $14,898 in total fines with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

210 Northwest 3rd Street, Pine Island, MN

(507) 356-8304

Compare this facility

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

70

Certified beds

Average residents

53

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1986-11-01

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

1.45

Registered nurse staffing · state 1.06 · national 0.68

LPN hours / resident day

0.72

Licensed practical nurse staffing · state 0.62 · national 0.87

Aide hours / resident day

2.69

Nurse aide staffing · state 2.56 · national 2.35

Total nurse hours

4.87

All reported nurse hours · state 4.23 · national 3.89

Licensed hours

2.17

RN + LPN hours · state 1.68 · national 1.54

Weekend hours

4.24

Weekend nurse staffing · state 3.68 · national 3.43

Weekend RN hours

0.95

Weekend registered nurse coverage · state 0.68 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.08 · national 0.07

Adjusted RN hours

1.65

CMS adjusted RN staffing hours

Adjusted total hours

5.52

CMS adjusted total nurse staffing hours

Case-mix index

1.21

Higher values indicate more complex resident acuity

RN turnover

65%

Annual RN turnover · state 39% · national 45%

Total nurse turnover

65%

Annual nurse turnover · state 42% · national 46%

SNF VBP

Value-based purchasing

Program rank

5,446

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

36.16

Composite VBP score used to determine payment impact.

Payment multiplier

0.9896

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

5.75

Baseline 19.37% · Performance 18.77% · Measure score 5.75 · Achievement 5.75 · Improvement 2.07

Healthcare-associated infections

2.84

Baseline 5.59% · Performance 6.99% · Measure score 2.84 · Achievement 2.84 · Improvement 0

Total nurse turnover

0.44

Baseline 73.56% · Performance 68.97% · Measure score 0.44 · Achievement 0 · Improvement 0.44

Adjusted total nurse staffing

5.43

Baseline 3.97 hours · Performance 4.62 hours · Measure score 5.43 · Achievement 5.43 · Improvement 3.11

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 10.7%
10.72%
About the same
No Different than the National Rate · Eligible stays 63 · Observed rate 12.7% · Lower 95% interval 6.97%
Discharge to community 47.46%
50.57%
3.1 pts worse
No Different than the National Rate · Eligible stays 65 · Observed rate 35.38% · Lower 95% interval 35.76%
Medicare spending per beneficiary 0.84
1.02
0.2 pts better
Drug regimen review with follow-up 98.63%
95.27%
3.4 pts better
Numerator 72 · Denominator 73
Falls with major injury 1.37%
0.77%
0.6 pts worse
Numerator 1 · Denominator 73
Discharge self-care score 36.73%
53.69%
17 pts worse
Numerator 18 · Denominator 49
Discharge mobility score 40.82%
50.94%
10.1 pts worse
Numerator 20 · Denominator 49
Pressure ulcers or injuries, new or worsened 2.74%
2.29%
0.5 pts worse
Numerator 2 · Denominator 73 · Adjusted rate 2.41%
Healthcare-associated infections requiring hospitalization 6.99%
7.12%
0.1 pts better
No Different than the National Rate · Eligible stays 58 · Observed rate 8.62% · Lower 95% interval 4.33%
Staff COVID-19 vaccination coverage 9.4%
8.2%
1.2 pts better
Numerator 11 · Denominator 117
Staff flu vaccination coverage 33.33%
42%
8.7 pts worse
Numerator 40 · Denominator 120
Discharge function score 42.86%
56.45%
13.6 pts worse
Numerator 21 · Denominator 49
Transfer of health information to provider Not Available
95.95%
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly.
Transfer of health information to patient 96.3%
96.28%
About the same
Numerator 26 · Denominator 27
Resident COVID-19 vaccinations up to date 45.71%
25.2%
20.5 pts better
Numerator 16 · Denominator 35

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 1.8
1.7
0.1 pts worse
1.9
0.1 pts better
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.0 · Expected 2.0 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 0.4
2.0
1.6 pts better
1.8
1.4 pts better
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.3 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 60.6%
97.3%
36.7 pts worse
93.4%
32.8 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 63.3% · Q2 58.3% · Q3 57.7% · Q4 63.6% · 4Q avg 60.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 94.4%
96.1%
1.7 pts worse
95.5%
1.1 pts worse
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.4%
Percentage of long-stay residents experiencing one or more falls with major injury 4.7%
3.9%
0.8 pts worse
3.3%
1.4 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 4.2% · Q3 3.8% · Q4 6.8% · 4Q avg 4.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 1.1%
4.3%
3.2 pts better
11.4%
10.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 2.3% · 4Q avg 1.1%
Percentage of long-stay residents who lose too much weight 6.8%
4.1%
2.7 pts worse
5.4%
1.4 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 5.6% · Q3 10.3% · Q4 8.3% · 4Q avg 6.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 7.2%
12.4%
5.2 pts better
19.6%
12.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 5.3% · Q3 7.7% · Q4 10.8% · 4Q avg 7.2%
Percentage of long-stay residents who received an antipsychotic medication 15.4%
17.5%
2.1 pts better
16.7%
1.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 14.3% · Q3 18.8% · Q4 18.8% · 4Q avg 15.4% · 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 23.1%
22.5%
0.6 pts worse
16.3%
6.8 pts worse
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.1% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 17.8%
18.6%
0.8 pts better
14.9%
2.9 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 23.7% · Q3 15.8% · Q4 13.9% · 4Q avg 17.8% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 3.7%
2.3%
1.4 pts worse
1.0%
2.7 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.8% · Q3 6.9% · Q4 3.4% · 4Q avg 3.7% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 1.6%
2.6%
1 pts better
1.7%
0.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.8% · Q4 2.3% · 4Q avg 1.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 32.4%
24.8%
7.6 pts worse
19.8%
12.6 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 36.6% · Q2 24.4% · Q3 27.4% · Q4 42.9% · 4Q avg 32.4%
Percentage of long-stay residents with pressure ulcers 6.0%
5.4%
0.6 pts worse
5.1%
0.9 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 3.4% · Q3 7.3% · Q4 8.4% · 4Q avg 6.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 84.8%
88.6%
3.8 pts worse
81.7%
3.1 pts better
Short Stay · 2024Q4-2025Q3 · Q1 81.0% · Q2 78.0% · Q3 90.4% · Q4 90.7% · 4Q avg 84.8%
Percentage of short-stay residents who had an outpatient emergency department visit 6.4%
14.0%
7.6 pts better
12.0%
5.6 pts better
Short Stay · 20240701-20250630 · Adjusted 6.4% · Observed 7.0% · Expected 12.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 4.4%
1.9%
2.5 pts worse
1.6%
2.8 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 5.9% · Q3 9.5% · Q4 0.0% · 4Q avg 4.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 87.7%
82.7%
5 pts better
79.7%
8 pts better
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 27.2%
23.1%
4.1 pts worse
23.9%
3.3 pts worse
Short Stay · 20240701-20250630 · Adjusted 27.2% · Observed 30.2% · Expected 26.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-28 · Fire 2025-08-28

6 health deficiencies

Top issue: Resident Rights (3 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2024-07-17 · Fire 2024-07-17

15 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

13 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)

Cycle 3 Health 2023-08-24 · Fire 2023-08-24

7 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

11 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-08-28

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-10-15

F · Potential for more than minimal harm 2025-08-28

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-10-15

F · Potential for more than minimal harm 2025-08-28

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-10-15

F · Potential for more than minimal harm 2025-08-28

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-10-15

F · Potential for more than minimal harm 2024-07-17

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-08-26

F · Potential for more than minimal harm 2024-07-17

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-08-26

F · Potential for more than minimal harm 2024-07-17

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-08-26

F · Potential for more than minimal harm 2024-07-17

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2024-08-26

F · Potential for more than minimal harm 2024-07-17

K541 · Services Deficiencies

Fire Safety

Install properly constructed and protected linen or trash chutes.

Corrected 2024-08-26

F · Potential for more than minimal harm 2024-07-17

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-08-26

F · Potential for more than minimal harm 2024-07-17

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 2024-08-26

F · Potential for more than minimal harm 2024-07-17

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-08-26

F · Potential for more than minimal harm 2024-07-17

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-08-26

F · Potential for more than minimal harm 2024-07-17

K926 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.

Corrected 2024-08-26

E · Potential for more than minimal harm 2024-07-17

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-08-26

D · Potential for more than minimal harm 2024-07-17

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-08-26

C · Minimal harm 2024-07-17

K901 · Electrical Deficiencies

Fire Safety

Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.

Corrected 2024-08-26

F · Potential for more than minimal harm 2023-08-24

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2023-10-04

F · Potential for more than minimal harm 2023-08-24

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-10-04

F · Potential for more than minimal harm 2023-08-24

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-10-04

F · Potential for more than minimal harm 2023-08-24

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2023-10-04

F · Potential for more than minimal harm 2023-08-24

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-10-04

F · Potential for more than minimal harm 2023-08-24

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-10-04

F · Potential for more than minimal harm 2023-08-24

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2023-10-04

F · Potential for more than minimal harm 2023-08-24

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 2023-10-04

F · Potential for more than minimal harm 2023-08-24

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-10-04

C · Minimal harm 2023-08-24

E24 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for volunteers.

Corrected 2023-10-04

C · Minimal harm 2023-08-24

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2023-10-13

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-08-28

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2025-10-15

D · Potential for more than minimal harm 2025-08-28

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2025-10-15

D · Potential for more than minimal harm 2025-08-28

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 2025-10-15

D · Potential for more than minimal harm 2025-08-28

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2025-10-15

D · Potential for more than minimal harm 2025-08-28

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-10-15

D · Potential for more than minimal harm 2025-08-28

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2025-10-15

D · Potential for more than minimal harm 2024-12-24

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-01-31

D · Potential for more than minimal harm 2024-12-24

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-01-31

D · Potential for more than minimal harm 2024-10-03

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-11-08

D · Potential for more than minimal harm 2024-10-03

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-11-08

F · Potential for more than minimal harm 2024-07-17

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-08-26

E · Potential for more than minimal harm 2024-07-17

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 2024-08-26

D · Potential for more than minimal harm 2024-07-17

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2024-08-26

D · Potential for more than minimal harm 2024-07-17

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-08-26

D · Potential for more than minimal harm 2024-07-17

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-08-26

D · Potential for more than minimal harm 2024-07-17

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-08-26

D · Potential for more than minimal harm 2024-07-17

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-08-26

D · Potential for more than minimal harm 2024-07-17

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2024-08-26

D · Potential for more than minimal harm 2024-07-17

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 2024-08-26

D · Potential for more than minimal harm 2024-07-17

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 2024-08-26

D · Potential for more than minimal harm 2024-07-17

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2024-08-26

G · Actual harm 2024-01-23

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 2024-01-17

D · Potential for more than minimal harm 2024-01-23

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-02-16

F · Potential for more than minimal harm 2023-08-24

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 2023-09-22

F · Potential for more than minimal harm 2023-08-24

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-10-03

D · Potential for more than minimal harm 2023-08-24

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2023-10-04

D · Potential for more than minimal harm 2023-08-24

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 2023-10-04

D · Potential for more than minimal harm 2023-08-24

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 2023-10-04

Penalties and ownership

What sits behind the stars

$14,898 2024-01-23

Fine

Fine · fine $14,898

Fine

Ownership

Nearby options

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2-star overall rating with 1-star inspections with 13 recent health deficiencies

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1-star overall rating with 1-star inspections with Special Focus status with 17 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

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#3

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3-star overall rating with 3-star inspections with $10,196 in total fines with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

Overall
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Health
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Staffing
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Fines
$10,196

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