Cycle 1
Health 2025-01-09 · Fire 2025-01-09
14 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Maplewood, MN
Harmony Gardens
4-star overall rating with 2-star inspections with 14 recent health deficiencies
1438 County Road C East, Maplewood, MN
(651) 488-6658
Overall
4 / 5
CMS overall stars
Health inspections
2 / 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
64
Certified beds
Average residents
62
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Cassia
Operator or chain grouping
Approved since
1986-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
16 facilities
Chain averages 5 overall / 4 health / 5 staffing / 4 quality stars
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
1.29
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.43
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.43
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
2.00
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.03
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
1.00
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.29
CMS adjusted RN staffing hours
Adjusted total hours
4.42
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
26%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,311
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.30
Composite VBP score used to determine payment impact.
Payment multiplier
1.0044
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.93% · Performance 21.87% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
6.30
Baseline 6.80% · Performance 5.95% · Measure score 6.30 · Achievement 6.30 · Improvement 4.21
Total nurse turnover
8.82
Baseline 25.00% · Performance 27.63% · Measure score 8.82 · Achievement 8.82 · Improvement 0
Adjusted total nurse staffing
5
Baseline 4.18 hours · Performance 4.50 hours · Measure score 5 · Achievement 5 · Improvement 1.50
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.16% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 120 · Observed rate 12.5% · Lower 95% interval 7.1% |
| Discharge to community | 68.87% |
50.57%
18.3 pts better
|
Better than the National Rate · Eligible stays 119 · Observed rate 62.18% · Lower 95% interval 60.51% |
| Medicare spending per beneficiary | 0.73 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.51% |
95.27%
3.2 pts better
|
Numerator 66 · Denominator 67 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 67 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 29 · Denominator 58 |
| Discharge mobility score | 56.9% |
50.94%
6 pts better
|
Numerator 33 · Denominator 58 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 67 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.95% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 70 · Observed rate 2.86% · Lower 95% interval 3.22% |
| Staff COVID-19 vaccination coverage | 1.13% |
8.2%
7.1 pts worse
|
Numerator 3 · Denominator 266 |
| Staff flu vaccination coverage | 14.29% |
42%
27.7 pts worse
|
Numerator 42 · Denominator 294 |
| Discharge function score | 58.62% |
56.45%
2.2 pts better
|
Numerator 34 · Denominator 58 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 80.77% |
96.28%
15.5 pts worse
|
Numerator 42 · Denominator 52 |
| Resident COVID-19 vaccinations up to date | 91.43% |
25.2%
66.2 pts better
|
Numerator 32 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
97.3%
1.5 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.1% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 98.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.6% |
96.1%
1.5 pts better
|
95.5%
2.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
3.9%
2.7 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.4% · Q4 2.5% · 4Q avg 1.2% · 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 5.3% · Q2 8.1% · Q3 5.7% · Q4 12.1% · 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 0.0% · Q2 0.0% · Q3 5.4% · Q4 2.9% · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.6% |
12.4%
6.8 pts better
|
19.6%
14 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 5.7% · Q3 5.4% · Q4 8.6% · 4Q avg 5.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.8% |
17.5%
10.7 pts better
|
16.7%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 6.2% · Q3 12.9% · Q4 0.0% · 4Q avg 6.8% · 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 | 28.1% |
22.5%
5.6 pts worse
|
16.3%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.2% |
18.6%
5.4 pts better
|
14.9%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 9.1% · Q3 13.9% · Q4 17.6% · 4Q avg 13.2% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
2.6%
0.8 pts better
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 0.0% · Q3 0.0% · Q4 2.5% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.4% |
24.8%
6.4 pts better
|
19.8%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 20.8% · Q3 5.1% · Q4 33.2% · 4Q avg 18.4% |
| Percentage of long-stay residents with pressure ulcers | 5.6% |
5.4%
0.2 pts worse
|
5.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 5.9% · Q3 5.6% · Q4 1.8% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.2% |
88.6%
4.6 pts better
|
81.7%
11.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.5% · Q2 93.4% · Q3 92.4% · Q4 91.8% · 4Q avg 93.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.4% |
14.0%
6.6 pts better
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 6.7% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.9%
1.7 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.1% |
82.7%
4.6 pts worse
|
79.7%
1.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.5% |
23.1%
1.6 pts better
|
23.9%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.5% · Observed 17.8% · Expected 19.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-09 · Fire 2023-11-09
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-02-03 · Fire 2023-02-03
11 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-06
E · Potential for more than minimal harm
2025-04-04
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-05-06
D · Potential for more than minimal harm
2025-04-04
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-05-06
D · Potential for more than minimal harm
2025-04-04
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-06
F · Potential for more than minimal harm
2025-01-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-09
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 2025-02-17
D · Potential for more than minimal harm
2025-01-09
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-09
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-09
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 2025-02-17
D · Potential for more than minimal harm
2025-01-09
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-09
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-09
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-09
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2025-02-17
G · Actual harm
2024-09-19
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 2024-09-18
D · Potential for more than minimal harm
2024-01-05
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-02-14
D · Potential for more than minimal harm
2023-11-09
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-12-19
D · Potential for more than minimal harm
2023-11-09
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-12-19
D · Potential for more than minimal harm
2023-11-09
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 2023-12-19
G · Actual harm
2023-02-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-15
E · Potential for more than minimal harm
2023-02-03
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 2023-03-15
D · Potential for more than minimal harm
2023-02-03
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-03-15
D · Potential for more than minimal harm
2023-02-03
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 2023-03-15
D · Potential for more than minimal harm
2023-02-03
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-03-15
D · Potential for more than minimal harm
2023-02-03
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-03-15
D · Potential for more than minimal harm
2023-02-03
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-03-15
D · Potential for more than minimal harm
2023-02-03
F777 · Administration Deficiencies
Health
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Corrected 2023-03-15
D · Potential for more than minimal harm
2023-02-03
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2023-03-15
D · Potential for more than minimal harm
2023-02-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-15
Penalties and ownership
What sits behind the stars
Ownership
Elim Care Inc
5% Or Greater Direct Ownership Interest · Organization
Cassia
Operational/Managerial Control · Organization
Dahl, Robert
Corporate Officer · Individual
Holmgren, Becky
W-2 Managing Employee · Individual
Kern, Matthew
Corporate Officer · Individual
Leff, William
Corporate Director · Individual
Nye, Gerald
Corporate Director · Individual
Peterson, Roland
Corporate Director · Individual
Tangedahl, Guy
Corporate Director · Individual
Youngquist, Kathryn
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Maplewood Rehabilitation Center
Maplewood, MN
1-star overall rating with 1-star inspections with 21 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Good Samaritan Society - Maplewood
Saint Paul, MN
3-star overall rating with 2-star inspections with 12 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Cerenity Care Center White Bear Lake
White Bear Lake, MN
5-star overall rating with 4-star inspections with $19,645 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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