Elk River, MN

Guardian Angels Care Center

2-star overall rating with 2-star inspections with $98,353 in total fines with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

400 Evans Avenue, Elk River, MN

(763) 635-5475

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 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

120

Certified beds

Average residents

104

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1967-01-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

1.50

Registered nurse staffing

LPN hours / resident day

0.65

Licensed practical nurse staffing

Aide hours / resident day

2.74

Nurse aide staffing

Weekend hours

4.18

Weekend nurse staffing

RN turnover

61%

Annual RN turnover

Total nurse turnover

47%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.7%	97.3% 2.4 pts better	93.4% 6.3 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.8%	96.1% 2.7 pts better	95.5% 3.3 pts better	Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury	2.3%	3.9% 1.6 pts better	3.3% 1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	2.7%	4.3% 1.6 pts better	11.4% 8.7 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	3.7%	4.1% 0.4 pts better	5.4% 1.7 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	5.7%	12.4% 6.7 pts better	19.6% 13.9 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	11.9%	17.5% 5.6 pts better	16.7% 4.8 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	59.6%	22.5% 37.1 pts worse	16.3% 43.3 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	18.1%	18.6% 0.5 pts better	14.9% 3.2 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	2.3% 2.3 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	3.0%	2.6% 0.4 pts worse	1.7% 1.3 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	31.9%	24.8% 7.1 pts worse	19.8% 12.1 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	2.4%	5.4% 3 pts better	5.1% 2.7 pts better	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	96.2%	88.6% 7.6 pts better	81.7% 14.5 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit	10.8%	14.0% 3.2 pts better	12.0% 1.2 pts better	Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication	2.2%	1.9% 0.3 pts worse	1.6% 0.6 pts worse	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	97.1%	82.7% 14.4 pts better	79.7% 17.4 pts better	Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission	27.9%	23.1% 4.8 pts worse	23.9% 4 pts worse	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-12-10 · Fire 2025-12-10

2 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 2 Health 2025-01-24 · Fire 2025-01-24

11 health deficiencies

Top issue: Nutrition and Dietary (3 deficiencies)

7 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2024-04-11 · Fire 2024-04-11

7 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

2 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2025-12-10

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 2025-12-26

D · Potential for more than minimal harm 2025-12-10

K930 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper storage of liquid oxygen.

Corrected 2025-12-26

C · Minimal harm 2025-12-10

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-12-26

E · Potential for more than minimal harm 2025-01-24

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 2025-03-24

E · Potential for more than minimal harm 2025-01-24

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-03-24

E · Potential for more than minimal harm 2025-01-24

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-03-24

D · Potential for more than minimal harm 2025-01-24

K226 · Egress Deficiencies

Fire Safety

Have horizontal exits used in accordance with safety requirements.

Corrected 2025-03-24

D · Potential for more than minimal harm 2025-01-24

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-03-24

D · Potential for more than minimal harm 2025-01-24

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-03-24

C · Minimal harm 2025-01-24

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2025-03-24

F · Potential for more than minimal harm 2024-04-11

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-05-06

D · Potential for more than minimal harm 2024-04-11

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-05-06

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-09-09

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-10-24

D · Potential for more than minimal harm 2025-04-24

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-05-20

L · Immediate jeopardy 2025-01-24

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-24

F · Potential for more than minimal harm 2025-01-24

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 2025-03-24

E · Potential for more than minimal harm 2025-01-24

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 2025-03-24

E · Potential for more than minimal harm 2025-01-24

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-03-24

D · Potential for more than minimal harm 2025-01-24

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-03-24

D · Potential for more than minimal harm 2025-01-24

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-03-24

D · Potential for more than minimal harm 2025-01-24

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-03-24

D · Potential for more than minimal harm 2024-09-12

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-10-09

J · Immediate jeopardy 2024-07-17

F806 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected 2024-07-11

J · Immediate jeopardy 2024-05-16

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 2024-06-07

J · Immediate jeopardy 2024-04-11

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2024-04-29

D · Potential for more than minimal harm 2024-04-11

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2024-05-06

D · Potential for more than minimal harm 2024-04-11

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2024-05-06

D · Potential for more than minimal harm 2024-04-11

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2024-05-06

D · Potential for more than minimal harm 2024-03-14

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-04-12

D · Potential for more than minimal harm 2023-05-10

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 2023-06-14

D · Potential for more than minimal harm 2023-05-10

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 2023-06-14

D · Potential for more than minimal harm 2023-05-10

F745 · Quality of Life and Care Deficiencies

Health

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Corrected 2023-06-14

Penalties and ownership

What sits behind the stars

$59,010 2025-01-24

Fine

Fine · fine $59,010

Fine

$0 2025-01-24

Payment Denial

Payment Denial · denial start 2025-02-26 · 26 days

26 day denial

$13,627 2024-07-17

Fine

Fine · fine $13,627

Fine

$16,801 2024-05-16

Fine

Fine · fine $16,801

Fine

$8,915 2024-03-14

Fine

Fine · fine $8,915

Fine

Ownership

Guardian Angels Health Services, Inc.

Operational/Managerial Control · Organization

0% 1 facilities 1967-01-01

Heinecke, Carlie

W-2 Managing Employee · Individual

0% 1 facilities 2024-05-06

Herrmann, Daryl

Corporate Officer · Individual

0% 1 facilities 2018-01-01

Krieger, Linda

Corporate Officer · Individual

0% 1 facilities 2010-04-15

Larson, Traci

Operational/Managerial Control · Individual

0% 1 facilities 2022-05-02

Larson, Traci

Corporate Officer · Individual

0% 1 facilities 2022-05-02

Larson, Traci

W-2 Managing Employee · Individual

0% 1 facilities 2022-05-02

Leclaire, Joyce