Cycle 1
Health 2025-04-17 · Fire 2025-04-17
9 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Sauk Rapids, MN
Good Shepherd Lutheran Home
5-star overall rating with 3-star inspections with $10,000 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1115 4th Avenue North, Sauk Rapids, MN
(320) 252-6525
Overall
5 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
146
Certified beds
Average residents
121
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1984-07-01
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
0.84
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.79
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
3.17
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.80
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.63
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.19
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
0.04
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.93
CMS adjusted RN staffing hours
Adjusted total hours
5.32
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
28%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,086
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
60.05
Composite VBP score used to determine payment impact.
Payment multiplier
1.0152
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.88
Baseline 22.18% · Performance 19.41% · Measure score 4.88 · Achievement 4.36 · Improvement 4.88
Healthcare-associated infections
5.74
Baseline 6.43% · Performance 6.12% · Measure score 5.74 · Achievement 5.74 · Improvement 1.65
Total nurse turnover
5.76
Baseline 45.03% · Performance 40.13% · Measure score 5.76 · Achievement 5.76 · Improvement 1.93
Adjusted total nurse staffing
7.65
Baseline 4.81 hours · Performance 5.25 hours · Measure score 7.65 · Achievement 7.65 · Improvement 4.07
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.74% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 112 · Observed rate 7.14% · Lower 95% interval 6.26% |
| Discharge to community | 57.63% |
50.57%
7.1 pts better
|
No Different than the National Rate · Eligible stays 111 · Observed rate 54.95% · Lower 95% interval 47.41% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 91.02% |
95.27%
4.2 pts worse
|
Numerator 152 · Denominator 167 |
| Falls with major injury | 0.6% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 167 |
| Discharge self-care score | 58.44% |
53.69%
4.8 pts better
|
Numerator 90 · Denominator 154 |
| Discharge mobility score | 52.6% |
50.94%
1.7 pts better
|
Numerator 81 · Denominator 154 |
| Pressure ulcers or injuries, new or worsened | 1.2% |
2.29%
1.1 pts better
|
Numerator 2 · Denominator 167 · Adjusted rate 1.49% |
| Healthcare-associated infections requiring hospitalization | 6.12% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 58 · Observed rate 1.72% · Lower 95% interval 2.97% |
| Staff COVID-19 vaccination coverage | 3.57% |
8.2%
4.6 pts worse
|
Numerator 9 · Denominator 252 |
| Staff flu vaccination coverage | 47.85% |
42%
5.9 pts better
|
Numerator 167 · Denominator 349 |
| Discharge function score | 63.64% |
56.45%
7.2 pts better
|
Numerator 98 · Denominator 154 |
| 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 | 95.73% |
96.28%
0.5 pts worse
|
Numerator 112 · Denominator 117 |
| Resident COVID-19 vaccinations up to date | 58.89% |
25.2%
33.7 pts better
|
Numerator 53 · Denominator 90 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.7
About the same
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.3 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
2.0
1.4 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.5 · 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 | 98.2% |
96.1%
2.1 pts better
|
95.5%
2.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.9%
1.2 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.9% · Q3 1.1% · Q4 2.9% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.7% |
4.3%
3.4 pts worse
|
11.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 7.8% · Q3 6.8% · Q4 6.4% · 4Q avg 7.7% |
| Percentage of long-stay residents who lose too much weight | 2.1% |
4.1%
2 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 1.4% · Q3 3.0% · Q4 0.0% · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.4% |
12.4%
1 pts worse
|
19.6%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 14.1% · Q3 11.8% · Q4 9.9% · 4Q avg 13.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.1% |
17.5%
2.4 pts better
|
16.7%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 15.3% · Q3 13.6% · Q4 16.7% · 4Q avg 15.1% · 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 | 28.0% |
22.5%
5.5 pts worse
|
16.3%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.0% · Q2 23.6% · Q3 26.1% · Q4 30.8% · 4Q avg 28.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.9% |
18.6%
2.3 pts worse
|
14.9%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 32.3% · Q3 13.1% · Q4 16.1% · 4Q avg 20.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
2.3%
1.6 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.9% · Q3 0.0% · Q4 0.9% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
2.6%
1.1 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 1.1% · Q4 2.9% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.7% |
24.8%
0.9 pts worse
|
19.8%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 32.1% · Q3 22.3% · Q4 25.7% · 4Q avg 25.7% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
5.4%
0.9 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 6.1% · Q3 3.4% · Q4 5.3% · 4Q avg 4.5% · 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 | 1.4% |
14.0%
12.6 pts better
|
12.0%
10.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 1.4% · Observed 1.3% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.9%
0.7 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 3.3% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.6% |
82.7%
7.9 pts better
|
79.7%
10.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.0% |
23.1%
9.1 pts better
|
23.9%
9.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.0% · Observed 11.4% · Expected 19.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-02 · Fire 2024-05-02
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2023-03-23 · Fire 2023-03-23
5 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-04-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-04-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-30
F · Potential for more than minimal harm
2024-05-02
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-06-12
F · Potential for more than minimal harm
2024-05-02
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-06-12
F · Potential for more than minimal harm
2024-05-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-08
F · Potential for more than minimal harm
2023-03-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-08
E · Potential for more than minimal harm
2023-03-23
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-05-08
E · Potential for more than minimal harm
2023-03-23
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 2023-05-08
B · Minimal harm
2023-03-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-08
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-17
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-06-11
F · Potential for more than minimal harm
2025-04-17
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-06-11
E · Potential for more than minimal harm
2025-04-17
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 2025-06-11
D · Potential for more than minimal harm
2025-04-17
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-06-11
D · Potential for more than minimal harm
2025-04-17
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-11
D · Potential for more than minimal harm
2025-04-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-11
D · Potential for more than minimal harm
2025-04-17
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 2025-06-11
D · Potential for more than minimal harm
2025-04-17
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-06-11
D · Potential for more than minimal harm
2025-04-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-11
E · Potential for more than minimal harm
2024-05-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-12
E · Potential for more than minimal harm
2024-05-02
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-05-02
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-05-02
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 2024-06-12
D · Potential for more than minimal harm
2024-05-02
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 2024-06-12
D · Potential for more than minimal harm
2024-05-02
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 2024-06-12
E · Potential for more than minimal harm
2023-03-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-08
D · Potential for more than minimal harm
2023-03-23
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-05-08
D · Potential for more than minimal harm
2023-03-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-05-08
D · Potential for more than minimal harm
2023-03-23
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 2023-05-08
D · Potential for more than minimal harm
2023-03-23
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 2023-05-08
Penalties and ownership
What sits behind the stars
$10,000
2023-03-23
Fine
Fine · fine $10,000
Fine
Ownership
Cloeter, Paul
Corporate Director · Individual
Douvier, Mark
Corporate Officer · Individual
Douvier, Mark
W-2 Managing Employee · Individual
Fitch, Mike
Corporate Officer · Individual
Hawkinson, Joyce
Corporate Director · Individual
Kersten, Dorothy
Corporate Director · Individual
Kirchoff, Barry
Corporate Director · Individual
Luedtke, Charles
Corporate Director · Individual
Machula, Jennifer
Corporate Director · Individual
Mahnke, Barbara
Corporate Director · Individual
Martini, Krista
W-2 Managing Employee · Individual
Stordahl, Michael
Corporate Officer · Individual
Stordahl, Michael
W-2 Managing Employee · Individual
Strohschein, David
Corporate Director · Individual
Studenski, Dennis
Corporate Director · Individual
Tomhave, Greg
Corporate Director · Individual
Zoeller, David
Corporate Director · Individual
Nearby options
Other facilities in reach
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Country Manor Health & Rehab Ctr
Sartell, MN
5-star overall rating with 4-star inspections with 2 recent health deficiencies
#2
Sterling Park Health Care Center
Waite Park, MN
2-star overall rating with 2-star inspections with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Edenbrook of St Cloud
Saint Cloud, MN
3-star overall rating with 3-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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