Cycle 1
Health 2025-11-20 · Fire 2025-11-20
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Wayzata, MN
Folkestone
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
100 Promenade Avenue, Wayzata, MN
(952) 249-2400
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
30
Certified beds
Average residents
27
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Presbyterian Homes & Services
Operator or chain grouping
Approved since
2014-06-06
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
20 facilities
Chain averages 4 overall / 3 health / 5 staffing / 3 quality stars
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
1.48
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.14
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
3.43
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
5.04
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.61
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.55
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
1.23
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.45
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.62
CMS adjusted RN staffing hours
Adjusted total hours
5.54
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
95
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
86.27
Composite VBP score used to determine payment impact.
Payment multiplier
1.0269
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
7.89
Baseline 25.71% · Performance 31.43% · Measure score 7.89 · Achievement 7.89 · Improvement 0
Adjusted total nurse staffing
9.36
Baseline 5 hours · Performance 5.74 hours · Measure score 9.36 · Achievement 9.36 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.87% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 4% · Lower 95% interval 6.77% |
| Discharge to community | 49.98% |
50.57%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 45 · Observed rate 44.44% · Lower 95% interval 37.53% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 14 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.27% |
8.2%
6.9 pts worse
|
Numerator 3 · Denominator 237 |
| Staff flu vaccination coverage | 2.42% |
42%
39.6 pts worse
|
Numerator 3 · Denominator 124 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 5 · 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 | 99.0% |
97.3%
1.7 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 76.9% |
96.1%
19.2 pts worse
|
95.5%
18.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 76.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.9% |
3.9%
2 pts worse
|
3.3%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 7.7% · Q3 7.4% · Q4 0.0% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.1% |
4.3%
1.8 pts worse
|
11.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 3.8% · Q3 3.8% · Q4 8.7% · 4Q avg 6.1% |
| 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 · 4Q avg 6.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.3% |
12.4%
0.1 pts better
|
19.6%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.1% |
17.5%
6.4 pts better
|
16.7%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.1% · 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 | 34.0% |
22.5%
11.5 pts worse
|
16.3%
17.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 34.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.3% |
18.6%
4.7 pts worse
|
14.9%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
2.3%
0.7 pts better
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 3.8% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
2.6%
0.6 pts better
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.7% · Q4 4.3% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.5% |
24.8%
7.7 pts worse
|
19.8%
12.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 39.3% · Q3 28.4% · Q4 35.0% · 4Q avg 32.5% |
| Percentage of long-stay residents with pressure ulcers | 9.7% |
5.4%
4.3 pts worse
|
5.1%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 11.8% · Q3 5.6% · Q4 12.2% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.8% |
88.6%
7.2 pts better
|
81.7%
14.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q4 96.4% · 4Q avg 95.8% |
| 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 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-17 · Fire 2024-10-17
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-12-07 · Fire 2023-12-07
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-11-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-12
F · Potential for more than minimal harm
2024-10-17
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-11-08
F · Potential for more than minimal harm
2024-10-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-08
F · Potential for more than minimal harm
2024-10-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-11-03
F · Potential for more than minimal harm
2024-10-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-03
F · Potential for more than minimal harm
2024-10-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-11-08
F · Potential for more than minimal harm
2024-10-17
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2024-11-04
F · Potential for more than minimal harm
2024-10-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-10-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-03
D · Potential for more than minimal harm
2024-10-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-20
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2026-01-09
D · Potential for more than minimal harm
2025-11-20
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2026-01-09
F · Potential for more than minimal harm
2024-10-17
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 2024-11-15
E · Potential for more than minimal harm
2024-10-17
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-17
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-11-15
C · Minimal harm
2024-10-17
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-11-08
D · Potential for more than minimal harm
2023-12-07
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 2024-01-09
D · Potential for more than minimal harm
2023-12-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-12-07
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-01-09
Penalties and ownership
What sits behind the stars
Ownership
Brehmer, Jacob
Operational/Managerial Control · Individual
Computershare Corporate Trust
5% Or Greater Security Interest · Organization
Computershare Corporate Trust
5% Or Greater Mortgage Interest · Organization
Fletcher, Jonathan
Operational/Managerial Control · Individual
Fletcher, Jonathan
Corporate Director · Individual
Fletcher, Jonathan
Corporate Officer · Individual
Meyer, Mark
Operational/Managerial Control · Individual
Meyer, Mark
Corporate Officer · Individual
Mielke, John
Operational/Managerial Control · Individual
Pederson, Mark
Corporate Director · Individual
Peterson, Heidi
Operational/Managerial Control · Individual
Peterson, Heidi
Corporate Director · Individual
Phs Management, LLC
Operational/Managerial Control · Organization
Presbyterian Homes And Services
5% Or Greater Direct Ownership Interest · Organization
Presbyterian Homes Housing And Assisted Living, Inc.
5% Or Greater Direct Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Hope Springs at Minnetonka
Minnetonka, MN
1-star overall rating with 1-star inspections with $9,496 in total fines with 16 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Allina Health Restorative Suites
Plymouth, MN
5-star overall rating with 3-star inspections with 3 recent health deficiencies
#3
Mission Nursing Home
Plymouth, MN
3-star overall rating with 2-star inspections with 10 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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