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
Staffing
Hours and turnover
RN hours / resident day
0.84
Registered nurse staffing
LPN hours / resident day
0.79
Licensed practical nurse staffing
Aide hours / resident day
3.17
Nurse aide staffing
Weekend hours
4.19
Weekend nurse staffing
RN turnover
28%
Annual RN turnover
Total nurse turnover
45%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
#1
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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