Cycle 1
Health 2025-05-21 · Fire 2025-05-21
9 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Grand Rapids, MN
Grand Village
5-star overall rating with 3-star inspections with $8,435 in total fines with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
923 Hale Lake Pointe, Grand Rapids, MN
(218) 326-0543
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
114
Certified beds
Average residents
59
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1986-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.97
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
1.20
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.66
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.83
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
2.17
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.45
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.55
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
1.10
CMS adjusted RN staffing hours
Adjusted total hours
5.45
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,218
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.94
Composite VBP score used to determine payment impact.
Payment multiplier
1.0052
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.86
Baseline 18.85% · Performance 19.64% · Measure score 3.86 · Achievement 3.86 · Improvement 0
Healthcare-associated infections
3.96
Baseline 5.13% · Performance 6.65% · Measure score 3.96 · Achievement 3.96 · Improvement 0
Total nurse turnover
5.79
Baseline 33.04% · Performance 40.00% · Measure score 5.79 · Achievement 5.79 · Improvement 0
Adjusted total nurse staffing
6.76
Baseline 5.42 hours · Performance 5 hours · Measure score 6.76 · Achievement 6.76 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.86% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 136 · Observed rate 10.29% · Lower 95% interval 7.13% |
| Discharge to community | 66.48% |
50.57%
15.9 pts better
|
Better than the National Rate · Eligible stays 128 · Observed rate 64.84% · Lower 95% interval 59.66% |
| Medicare spending per beneficiary | 0.75 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 169 · Denominator 169 |
| Falls with major injury | 1.18% |
0.77%
0.4 pts worse
|
Numerator 2 · Denominator 169 |
| Discharge self-care score | 85.82% |
53.69%
32.1 pts better
|
Numerator 115 · Denominator 134 |
| Discharge mobility score | 79.85% |
50.94%
28.9 pts better
|
Numerator 107 · Denominator 134 |
| Pressure ulcers or injuries, new or worsened | 1.78% |
2.29%
0.5 pts better
|
Numerator 3 · Denominator 169 · Adjusted rate 2.38% |
| Healthcare-associated infections requiring hospitalization | 6.65% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 81 · Observed rate 4.94% · Lower 95% interval 3.4% |
| Staff COVID-19 vaccination coverage | 2.59% |
8.2%
5.6 pts worse
|
Numerator 5 · Denominator 193 |
| Staff flu vaccination coverage | 61.07% |
42%
19.1 pts better
|
Numerator 80 · Denominator 131 |
| Discharge function score | 85.82% |
56.45%
29.4 pts better
|
Numerator 115 · Denominator 134 |
| Transfer of health information to provider | 96.88% |
95.95%
0.9 pts better
|
Numerator 31 · Denominator 32 |
| Transfer of health information to patient | 99.15% |
96.28%
2.9 pts better
|
Numerator 116 · Denominator 117 |
| Resident COVID-19 vaccinations up to date | 36.59% |
25.2%
11.4 pts better
|
Numerator 30 · Denominator 82 |
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 | 1.1% |
3.9%
2.8 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.1% · Q4 2.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.3%
4.3 pts better
|
11.4%
11.4 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 who lose too much weight | 0.7% |
4.1%
3.4 pts better
|
5.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.7% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.0% |
12.4%
2.4 pts better
|
19.6%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 11.1% · Q3 13.5% · Q4 7.9% · 4Q avg 10.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.8% |
17.5%
3.7 pts better
|
16.7%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 13.3% · Q3 12.9% · Q4 15.6% · 4Q avg 13.8% · 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 | 11.1% |
22.5%
11.4 pts better
|
16.3%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.8% |
18.6%
7.8 pts better
|
14.9%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 8.3% · Q3 16.7% · Q4 7.9% · 4Q avg 10.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
2.3%
1.7 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
2.6%
1.5 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 2.1% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.1% |
24.8%
5.3 pts worse
|
19.8%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.8% · Q2 39.0% · Q3 16.2% · Q4 32.4% · 4Q avg 30.1% |
| Percentage of long-stay residents with pressure ulcers | 7.3% |
5.4%
1.9 pts worse
|
5.1%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 7.5% · Q3 12.4% · Q4 6.2% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
88.6%
9.5 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 99.3% · Q3 98.6% · Q4 95.7% · 4Q avg 98.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 28.3% |
14.0%
14.3 pts worse
|
12.0%
16.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.3% · Observed 25.7% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.9%
0.6 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.1% · Q3 0.0% · Q4 1.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.3% |
82.7%
6.6 pts better
|
79.7%
9.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.4% |
23.1%
4.7 pts better
|
23.9%
5.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.4% · Observed 15.7% · Expected 20.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-29 · Fire 2024-08-29
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-09-27 · Fire 2023-09-27
5 health deficiencies
Top issue: Infection Control (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-06-25
F · Potential for more than minimal harm
2025-05-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-25
F · Potential for more than minimal harm
2025-05-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-25
E · Potential for more than minimal harm
2025-05-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-25
F · Potential for more than minimal harm
2024-08-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-30
F · Potential for more than minimal harm
2023-09-27
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 2023-10-20
F · Potential for more than minimal harm
2023-09-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-10-20
F · Potential for more than minimal harm
2023-09-27
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-09-27
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-09-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-09-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-11-01
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-21
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 2025-06-20
D · Potential for more than minimal harm
2025-05-21
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-21
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-21
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-21
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-04-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-09
D · Potential for more than minimal harm
2024-08-29
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-09-23
D · Potential for more than minimal harm
2024-08-29
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-09-23
D · Potential for more than minimal harm
2024-08-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-23
D · Potential for more than minimal harm
2024-08-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-23
D · Potential for more than minimal harm
2024-08-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-23
D · Potential for more than minimal harm
2024-08-29
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-09-23
D · Potential for more than minimal harm
2024-07-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-19
F · Potential for more than minimal harm
2023-09-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-02
E · Potential for more than minimal harm
2023-09-27
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-27
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-10-23
E · Potential for more than minimal harm
2023-09-12
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 2023-09-27
J · Immediate jeopardy
2023-04-28
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 2023-04-19
Penalties and ownership
What sits behind the stars
$8,435
2023-04-28
Fine
Fine · fine $8,435
Fine
Ownership
County Of Itasca
5% Or Greater Direct Ownership Interest · Organization
Bell, Brittany
Operational/Managerial Control · Individual
Ebenezer Management Services Inc
Operational/Managerial Control · Organization
Johnson, John
Corporate Director · Individual
Oliverius, Maggie
Operational/Managerial Control · Individual
Rohling, Austin
Corporate Director · Individual
Smith, Cory
Corporate Director · Individual
Snyder, Terry
Corporate Director · Individual
Trunt, Leo
Corporate Director · Individual
Venema, Matthew
Corporate Director · Individual
Willett, Todd
Operational/Managerial Control · Individual
Youngdahl-Palecek, Antoinette
Operational/Managerial Control · Individual
Nearby options
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#2
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2-star overall rating with 1-star inspections with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Guardian Angels Health & Rehab Center
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2-star overall rating with 1-star inspections with $32,968 in total fines with 16 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
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