Cycle 1
Health 2025-03-12 · Fire 2025-03-12
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Rushford, MN
Good Shepherd Lutheran Home
5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
800 Home Street, Box 747, Rushford, MN
(507) 864-7714
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
65
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
1986-12-01
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
0.57
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.75
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.23
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.48
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.49
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.71
CMS adjusted RN staffing hours
Adjusted total hours
5.26
CMS adjusted total nurse staffing hours
Case-mix index
1.10
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
535
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
68.12
Composite VBP score used to determine payment impact.
Payment multiplier
1.0214
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
4.85
Baseline 42.86% · Performance 43.84% · Measure score 4.85 · Achievement 4.85 · Improvement 0
Adjusted total nurse staffing
8.77
Baseline 4.72 hours · Performance 5.57 hours · Measure score 8.77 · Achievement 8.77 · Improvement 7.53
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 17 · 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 17 · 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 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 3.96% |
8.2%
4.2 pts worse
|
Numerator 4 · Denominator 101 |
| Staff flu vaccination coverage | 11.38% |
42%
30.6 pts worse
|
Numerator 14 · Denominator 123 |
| 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 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · 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 | 89.7% |
97.3%
7.6 pts worse
|
93.4%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 90.9% · Q2 91.3% · Q3 95.6% · Q4 81.6% · 4Q avg 89.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.9% |
96.1%
1.8 pts better
|
95.5%
2.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.3% |
3.9%
0.4 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.3% · Q3 4.4% · Q4 4.1% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.9% |
4.3%
1.4 pts better
|
11.4%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 6.7% · Q3 0.0% · Q4 2.1% · 4Q avg 2.9% |
| Percentage of long-stay residents who lose too much weight | 5.4% |
4.1%
1.3 pts worse
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 7.5% · Q3 4.9% · Q4 4.3% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.2% |
12.4%
4.2 pts better
|
19.6%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 9.8% · Q3 7.1% · Q4 6.5% · 4Q avg 8.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.2% |
17.5%
12.3 pts better
|
16.7%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 2.6% · Q3 5.1% · Q4 4.9% · 4Q avg 5.2% · 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 | 23.3% |
22.5%
0.8 pts worse
|
16.3%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 24.2% · Q3 24.1% · Q4 20.6% · 4Q avg 23.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.6% |
18.6%
2 pts better
|
14.9%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 15.0% · Q3 15.0% · Q4 18.2% · 4Q avg 16.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.6% |
2.3%
1.3 pts worse
|
1.0%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 3.8% · Q3 2.1% · Q4 3.7% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
2.6%
0.4 pts better
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.2% · Q3 0.0% · Q4 4.1% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.1% |
24.8%
2.3 pts worse
|
19.8%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.3% · Q2 22.8% · Q3 21.9% · Q4 28.5% · 4Q avg 27.1% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
5.4%
0.1 pts better
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 7.1% · Q3 2.5% · Q4 2.2% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 29.9% |
88.6%
58.7 pts worse
|
81.7%
51.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 55.0% · Q2 30.0% · Q3 19.0% · 4Q avg 29.9% |
| 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 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.3% |
82.7%
8.6 pts better
|
79.7%
11.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.3% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-25 · Fire 2024-01-25
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-10-12 · Fire 2022-10-12
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-28
F · Potential for more than minimal harm
2025-03-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-04-01
F · Potential for more than minimal harm
2025-03-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-04-01
F · Potential for more than minimal harm
2024-01-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-14
F · Potential for more than minimal harm
2024-01-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-16
F · Potential for more than minimal harm
2024-01-25
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Not marked corrected
F · Potential for more than minimal harm
2024-01-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-02-09
D · Potential for more than minimal harm
2024-01-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-02-09
D · Potential for more than minimal harm
2024-01-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-01-25
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-02-09
F · Potential for more than minimal harm
2022-10-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-01
F · Potential for more than minimal harm
2022-10-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-10
F · Potential for more than minimal harm
2022-10-12
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-10-18
F · Potential for more than minimal harm
2022-10-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-11-18
F · Potential for more than minimal harm
2022-10-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-11
E · Potential for more than minimal harm
2022-10-12
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2022-11-21
E · Potential for more than minimal harm
2022-10-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-11-10
E · Potential for more than minimal harm
2022-10-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-10-10
D · Potential for more than minimal harm
2022-10-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-11-10
D · Potential for more than minimal harm
2022-10-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-10-11
C · Minimal harm
2022-10-12
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-11-11
C · Minimal harm
2022-10-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-11-10
C · Minimal harm
2022-10-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-11-09
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-02-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-06
D · Potential for more than minimal harm
2024-01-25
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-01-25
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-02-29
D · Potential for more than minimal harm
2022-10-12
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-11-24
D · Potential for more than minimal harm
2022-10-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-11-24
Penalties and ownership
What sits behind the stars
Ownership
Benson, Randy
Corporate Director · Individual
Colbenson, Samantha
Operational/Managerial Control · Individual
Cook, Sonja
Corporate Director · Individual
Culhane, John
Corporate Director · Individual
Culhane, John
Corporate Officer · Individual
Ebner, Wendy
Corporate Director · Individual
Hatlevig, Dean
Corporate Director · Individual
Ingram, Kathryn
Corporate Director · Individual
Pronk, Judith
Corporate Director · Individual
Snyder, Nancy
Corporate Director · Individual
Spece, Rhonda
Operational/Managerial Control · Individual
Usda Department Of Agriculture Rural Development
5% Or Greater Mortgage Interest · Organization
Zoelle-Johnson, Barbara
Corporate Director · Individual
Zoelle-Johnson, Barbara
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Valley View Healthcare & Rehab
Houston, MN
5-star overall rating with 4-star inspections with $26,685 in total fines with 7 fire-safety deficiencies in the latest cycle
#2
Lake Winona Manor
Winona, MN
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Tweeten Lutheran Health Care Center
Spring Grove, MN
1-star overall rating with 1-star inspections with $120,876 in total fines with 14 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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