Detroit Lakes, MN

Emmanuel Nursing Home

3-star overall rating with 2-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

1415 Madison Avenue, Detroit Lakes, MN

(218) 847-4486

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

57

Certified beds

Average residents

50

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1987-01-01

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

1.62

Registered nurse staffing · state 1.06 · national 0.68

LPN hours / resident day

0.53

Licensed practical nurse staffing · state 0.62 · national 0.87

Aide hours / resident day

2.35

Nurse aide staffing · state 2.56 · national 2.35

Total nurse hours

4.50

All reported nurse hours · state 4.23 · national 3.89

Licensed hours

2.15

RN + LPN hours · state 1.68 · national 1.54

Weekend hours

3.79

Weekend nurse staffing · state 3.68 · national 3.43

Weekend RN hours

0.89

Weekend registered nurse coverage · state 0.68 · national 0.47

Physical therapist

0.16

Reported PT staffing · state 0.08 · national 0.07

Adjusted RN hours

1.69

CMS adjusted RN staffing hours

Adjusted total hours

4.69

CMS adjusted total nurse staffing hours

Case-mix index

1.31

Higher values indicate more complex resident acuity

RN turnover

28%

Annual RN turnover · state 39% · national 45%

Total nurse turnover

44%

Annual nurse turnover · state 42% · national 46%

SNF VBP

Value-based purchasing

Program rank

1,742

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

Performance score

54.27

Composite VBP score used to determine payment impact.

Payment multiplier

1.0091

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.05

Baseline 19.86% · Performance 19.55% · Measure score 4.05 · Achievement 4.05 · Improvement 0.59

Healthcare-associated infections

7.67

Baseline 6.77% · Performance 5.54% · Measure score 7.67 · Achievement 7.67 · Improvement 6.41

Total nurse turnover

5.64

Baseline 36.05% · Performance 40.62% · Measure score 5.64 · Achievement 5.64 · Improvement 0

Adjusted total nurse staffing

4.35

Baseline 4.76 hours · Performance 4.31 hours · Measure score 4.35 · Achievement 4.35 · Improvement 0

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 142 · Observed rate 7.75% · Lower 95% interval 6.56%
Discharge to community	60.99%	50.57% 10.4 pts better	Better than the National Rate · Eligible stays 138 · Observed rate 58.7% · Lower 95% interval 51.75%
Medicare spending per beneficiary	0.72	1.02 0.3 pts better
Drug regimen review with follow-up	98.98%	95.27% 3.7 pts better	Numerator 97 · Denominator 98
Falls with major injury	1.02%	0.77% 0.2 pts worse	Numerator 1 · Denominator 98
Discharge self-care score	58.44%	53.69% 4.8 pts better	Numerator 45 · Denominator 77
Discharge mobility score	68.83%	50.94% 17.9 pts better	Numerator 53 · Denominator 77
Pressure ulcers or injuries, new or worsened	2.04%	2.29% 0.2 pts better	Numerator 2 · Denominator 98 · Adjusted rate 2.56%
Healthcare-associated infections requiring hospitalization	5.54%	7.12% 1.6 pts better	No Different than the National Rate · Eligible stays 91 · Observed rate 2.2% · Lower 95% interval 2.79%
Staff COVID-19 vaccination coverage	0.75%	8.2% 7.4 pts worse	Numerator 1 · Denominator 133
Staff flu vaccination coverage	13.33%	42% 28.7 pts worse	Numerator 22 · Denominator 165
Discharge function score	66.23%	56.45% 9.8 pts better	Numerator 51 · Denominator 77
Transfer of health information to provider	96.61%	95.95% 0.7 pts better	Numerator 57 · Denominator 59
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	50%	25.2% 24.8 pts better	Numerator 25 · Denominator 50

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	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	0.7%	3.9% 3.2 pts better	3.3% 2.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 0.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.4%	4.3% 2.9 pts better	11.4% 10 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4%
Percentage of long-stay residents who lose too much weight	5.8%	4.1% 1.7 pts worse	5.4% 0.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 3.4% · Q3 3.2% · Q4 10.0% · 4Q avg 5.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	11.5%	12.4% 0.9 pts better	19.6% 8.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 10.0% · Q3 12.9% · Q4 13.3% · 4Q avg 11.5%
Percentage of long-stay residents who received an antipsychotic medication	27.6%	17.5% 10.1 pts worse	16.7% 10.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 27.3% · Q3 26.9% · Q4 28.0% · 4Q avg 27.6% · 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	24.0%	22.5% 1.5 pts worse	16.3% 7.7 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 24.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	7.0%	18.6% 11.6 pts better	14.9% 7.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 3.6% · Q3 6.9% · Q4 7.1% · 4Q avg 7.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	5.5%	2.3% 3.2 pts worse	1.0% 4.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 4.9% · Q3 5.9% · Q4 6.4% · 4Q avg 5.5% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	6.9%	2.6% 4.3 pts worse	1.7% 5.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 5.6% · Q3 2.6% · Q4 8.8% · 4Q avg 6.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	20.8%	24.8% 4 pts better	19.8% 1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 13.6% · Q3 21.5% · Q4 24.6% · 4Q avg 20.8%
Percentage of long-stay residents with pressure ulcers	8.9%	5.4% 3.5 pts worse	5.1% 3.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 8.2% · Q3 11.0% · Q4 8.7% · 4Q avg 8.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.6%	88.6% 11 pts better	81.7% 17.9 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.2% · Q3 100.0% · Q4 99.3% · 4Q avg 99.6%
Percentage of short-stay residents who had an outpatient emergency department visit	12.1%	14.0% 1.9 pts better	12.0% 0.1 pts worse	Short Stay · 20240701-20250630 · Adjusted 12.1% · Observed 11.2% · Expected 10.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	3.4%	1.9% 1.5 pts worse	1.6% 1.8 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 5.1% · Q3 2.2% · Q4 3.5% · 4Q avg 3.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	93.8%	82.7% 11.1 pts better	79.7% 14.1 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 93.8%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	26.9%	23.1% 3.8 pts worse	23.9% 3 pts worse	Short Stay · 20240701-20250630 · Adjusted 26.9% · Observed 23.8% · Expected 21.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2026-02-11 · Fire 2026-02-11

5 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2024-12-18 · Fire 2024-12-18

6 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 3 Health 2023-10-04 · Fire 2023-10-04

8 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2026-02-11

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2026-02-11

E · Potential for more than minimal harm 2026-02-11

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2026-02-23

D · Potential for more than minimal harm 2026-02-11

K374 · Smoke Deficiencies

Fire Safety

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

Corrected 2026-02-11

D · Potential for more than minimal harm 2024-12-18

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-12-24

F · Potential for more than minimal harm 2023-10-04

K291 · Egress Deficiencies

Fire Safety

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

Corrected 2023-11-05

F · Potential for more than minimal harm 2023-10-04

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 2023-11-05

D · Potential for more than minimal harm 2023-10-04

K361 · Smoke Deficiencies

Fire Safety

Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.

Corrected 2023-11-05

Inspection history

Recent health citations

D · Potential for more than minimal harm 2026-02-11

F554 · Resident Rights Deficiencies

Health

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

Corrected 2026-02-23

D · Potential for more than minimal harm 2026-02-11

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2026-02-23

D · Potential for more than minimal harm 2026-02-11

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 2026-02-23

D · Potential for more than minimal harm 2026-02-11

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2026-02-23

J · Immediate jeopardy 2026-01-28

F808 · Nutrition and Dietary Deficiencies

Health

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Corrected 2026-02-23

G · Actual harm 2025-02-20

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-03-12

D · Potential for more than minimal harm 2025-02-20

F835 · Administration Deficiencies

Health

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected 2025-03-12

D · Potential for more than minimal harm 2025-01-30

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-03-04

D · Potential for more than minimal harm 2024-12-18

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 2025-01-20

D · Potential for more than minimal harm 2024-12-18

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 2025-01-20

D · Potential for more than minimal harm 2024-12-18

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-01-20

E · Potential for more than minimal harm 2023-10-04

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2023-11-05

E · Potential for more than minimal harm 2023-10-04

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-11-05

E · Potential for more than minimal harm 2023-10-04

F883 · Infection Control Deficiencies

Health

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

Corrected 2023-11-05

D · Potential for more than minimal harm 2023-10-04

F554 · Resident Rights Deficiencies

Health

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

Corrected 2023-11-05

D · Potential for more than minimal harm 2023-10-04

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 2023-11-05

D · Potential for more than minimal harm 2023-10-04

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-11-05

D · Potential for more than minimal harm 2023-10-04

F685 · Quality of Life and Care Deficiencies

Health

Assist a resident in gaining access to vision and hearing services.

Corrected 2023-11-05

D · Potential for more than minimal harm 2023-10-04

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 2023-11-05

Penalties and ownership

What sits behind the stars

Ownership

Cdl Homes, LLC

5% Or Greater Direct Ownership Interest · Organization

100% 1 facilities 2004-06-28

Andresen, Angelica