Cycle 1
Health 2024-12-16 · Fire 2024-12-16
19 health deficiencies
Top issue: Resident Rights (6 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Hopkins, MN
Hopkins Restorative Care Center
1-star overall rating with 1-star inspections with 19 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
725 Second Avenue South, Hopkins, MN
(952) 935-3338
Overall
1 / 5
CMS overall stars
Health inspections
1 / 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
118
Certified beds
Average residents
35
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
North Shore Healthcare
Operator or chain grouping
Approved since
1985-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.56
Registered nurse staffing
LPN hours / resident day
1.49
Licensed practical nurse staffing
Aide hours / resident day
2.25
Nurse aide staffing
Weekend hours
3.79
Weekend nurse staffing
RN turnover
50%
Annual RN turnover
Total nurse turnover
23%
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 | 99.3% |
97.3%
2 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.7% |
96.1%
1.4 pts worse
|
95.5%
0.8 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.9% |
3.9%
2 pts worse
|
3.3%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
4.3%
3.4 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.4% |
4.1%
0.3 pts worse
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.8% |
12.4%
4.4 pts worse
|
19.6%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 31.1% |
17.5%
13.6 pts worse
|
16.7%
14.4 pts worse
|
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 | 12.9% |
22.5%
9.6 pts better
|
16.3%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.2% |
18.6%
3.6 pts worse
|
14.9%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.0% |
2.3%
0.3 pts better
|
1.0%
1 pts worse
|
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 | 21.9% |
24.8%
2.9 pts better
|
19.8%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.0% |
88.6%
13.6 pts worse
|
81.7%
6.7 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 9.3% |
1.9%
7.4 pts worse
|
1.6%
7.7 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 59.5% |
82.7%
23.2 pts worse
|
79.7%
20.2 pts worse
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-01 · Fire 2024-03-01
14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-12-21 · Fire 2022-12-21
14 health deficiencies
Top issue: Resident Rights (4 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-16
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-01-31
F · Potential for more than minimal harm
2024-12-16
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-01-31
F · Potential for more than minimal harm
2024-12-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-16
F · Potential for more than minimal harm
2024-12-16
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-01-16
F · Potential for more than minimal harm
2024-12-16
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2025-01-16
F · Potential for more than minimal harm
2024-12-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-16
E · Potential for more than minimal harm
2024-12-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-16
E · Potential for more than minimal harm
2024-12-16
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-01-16
E · Potential for more than minimal harm
2024-12-16
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Not marked corrected
E · Potential for more than minimal harm
2024-12-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-16
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-16
K930 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper storage of liquid oxygen.
Corrected 2025-01-16
C · Minimal harm
2024-12-16
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-01-16
C · Minimal harm
2024-12-16
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-01-16
B · Minimal harm
2024-12-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-16
F · Potential for more than minimal harm
2024-03-01
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-03-31
F · Potential for more than minimal harm
2024-03-01
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-04-05
F · Potential for more than minimal harm
2024-03-01
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-04-05
F · Potential for more than minimal harm
2024-03-01
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-31
F · Potential for more than minimal harm
2024-03-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-15
E · Potential for more than minimal harm
2024-03-01
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 2024-04-12
E · Potential for more than minimal harm
2024-03-01
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-25
E · Potential for more than minimal harm
2024-03-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-10
E · Potential for more than minimal harm
2024-03-01
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-31
D · Potential for more than minimal harm
2024-03-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-03-01
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-14
F · Potential for more than minimal harm
2022-12-21
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Not marked corrected
F · Potential for more than minimal harm
2022-12-21
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Not marked corrected
F · Potential for more than minimal harm
2022-12-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Not marked corrected
F · Potential for more than minimal harm
2022-12-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Not marked corrected
F · Potential for more than minimal harm
2022-12-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Not marked corrected
F · Potential for more than minimal harm
2022-12-21
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Not marked corrected
F · Potential for more than minimal harm
2022-12-21
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.
Not marked corrected
E · Potential for more than minimal harm
2022-12-21
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 2023-01-11
E · Potential for more than minimal harm
2022-12-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-11
D · Potential for more than minimal harm
2022-12-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Not marked corrected
C · Minimal harm
2022-12-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-11
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-12-16
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-01-31
F · Potential for more than minimal harm
2024-12-16
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-01-31
F · Potential for more than minimal harm
2024-12-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-31
F · Potential for more than minimal harm
2024-12-16
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-02-15
E · Potential for more than minimal harm
2024-12-16
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 2025-01-07
E · Potential for more than minimal harm
2024-12-16
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-16
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 2025-01-31
D · Potential for more than minimal harm
2024-12-16
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 2025-01-31
D · Potential for more than minimal harm
2024-12-16
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-16
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 2025-02-15
D · Potential for more than minimal harm
2024-12-16
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-16
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 2025-01-31
D · Potential for more than minimal harm
2024-12-16
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-16
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 2025-01-31
D · Potential for more than minimal harm
2024-12-16
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-16
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 2025-01-31
D · Potential for more than minimal harm
2024-12-16
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-01-13
C · Minimal harm
2024-12-16
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2025-01-31
C · Minimal harm
2024-12-16
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-01-21
D · Potential for more than minimal harm
2024-10-02
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 2024-10-24
D · Potential for more than minimal harm
2024-10-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-24
F · Potential for more than minimal harm
2024-03-01
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 2024-03-31
F · Potential for more than minimal harm
2024-03-01
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-03-31
E · Potential for more than minimal harm
2024-03-01
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 2024-03-31
D · Potential for more than minimal harm
2024-03-01
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 2024-03-31
D · Potential for more than minimal harm
2024-03-01
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-03-31
D · Potential for more than minimal harm
2024-03-01
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-03-31
D · Potential for more than minimal harm
2024-03-01
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-03-31
D · Potential for more than minimal harm
2024-03-01
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-31
D · Potential for more than minimal harm
2024-03-01
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 2024-03-31
D · Potential for more than minimal harm
2024-03-01
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 2024-03-31
D · Potential for more than minimal harm
2024-03-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-31
D · Potential for more than minimal harm
2024-03-01
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-03-31
D · Potential for more than minimal harm
2023-09-13
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-10-27
F · Potential for more than minimal harm
2022-12-21
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 2023-01-26
F · Potential for more than minimal harm
2022-12-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-26
E · Potential for more than minimal harm
2022-12-21
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-01-26
E · Potential for more than minimal harm
2022-12-21
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-01-26
E · Potential for more than minimal harm
2022-12-21
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-01-26
E · Potential for more than minimal harm
2022-12-21
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-01-26
D · Potential for more than minimal harm
2022-12-21
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 2023-01-26
D · Potential for more than minimal harm
2022-12-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-01-26
D · Potential for more than minimal harm
2022-12-21
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 2023-01-26
D · Potential for more than minimal harm
2022-12-21
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-01-26
D · Potential for more than minimal harm
2022-12-21
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-01-26
C · Minimal harm
2022-12-21
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-01-26
C · Minimal harm
2022-12-21
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2023-01-26
Penalties and ownership
What sits behind the stars
Ownership
Nshc Wisconsin LLC
5% Or Greater Direct Ownership Interest · Organization
Baumann, Troy
5% Or Greater Indirect Ownership Interest · Individual
Hoehn, Jeffrey
5% Or Greater Indirect Ownership Interest · Individual
Baumann, Troy
Operational/Managerial Control · Individual
Baumann, Troy
Corporate Officer · Individual
Hoehn, Jeffrey
Operational/Managerial Control · Individual
Hoehn, Jeffrey
Corporate Officer · Individual
North Shore Healthcare LLC
Operational/Managerial Control · Organization
Nshc Wisconsin LLC
Operational/Managerial Control · Organization
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