Cycle 1
Health 2025-04-03 · Fire 2025-04-03
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Spring Park, MN
Lake Minnetonka Shores
5-star overall rating with 4-star inspections with $8,827 in total fines
4527 Shoreline Drive, Spring Park, MN
(952) 471-4001
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
53
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Presbyterian Homes & Services
Operator or chain grouping
Approved since
1977-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 4 overall / 3 health / 5 staffing / 3 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
1.27
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.46
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.58
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.31
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.73
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.90
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
1.05
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.21
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.46
CMS adjusted RN staffing hours
Adjusted total hours
4.97
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,160
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.20
Composite VBP score used to determine payment impact.
Payment multiplier
0.9905
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.84
Baseline 17.29% · Performance 19.65% · Measure score 3.84 · Achievement 3.84 · Improvement 0
Healthcare-associated infections
2.12
Baseline 5.36% · Performance 7.20% · Measure score 2.12 · Achievement 2.12 · Improvement 0
Total nurse turnover
3.60
Baseline 23.08% · Performance 48.98% · Measure score 3.60 · Achievement 3.60 · Improvement 0
Adjusted total nurse staffing
5.32
Baseline 5.20 hours · Performance 4.59 hours · Measure score 5.32 · Achievement 5.32 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.79% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 89 · Observed rate 8.99% · Lower 95% interval 6.85% |
| Discharge to community | 50.08% |
50.57%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 91 · Observed rate 47.25% · Lower 95% interval 40.64% |
| Medicare spending per beneficiary | 0.69 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 95.24% |
95.27%
About the same
|
Numerator 40 · Denominator 42 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 42 |
| Discharge self-care score | 51.35% |
53.69%
2.3 pts worse
|
Numerator 19 · Denominator 37 |
| Discharge mobility score | 29.73% |
50.94%
21.2 pts worse
|
Numerator 11 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 42 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.2% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 51 · Observed rate 5.88% · Lower 95% interval 4.09% |
| Staff COVID-19 vaccination coverage | 0.51% |
8.2%
7.7 pts worse
|
Numerator 2 · Denominator 390 |
| Staff flu vaccination coverage | 3.47% |
42%
38.5 pts worse
|
Numerator 12 · Denominator 346 |
| Discharge function score | 64.86% |
56.45%
8.4 pts better
|
Numerator 24 · Denominator 37 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 21 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 60% |
25.2%
34.8 pts better
|
Numerator 12 · Denominator 20 |
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 | 84.6% |
96.1%
11.5 pts worse
|
95.5%
10.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 84.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.9% |
3.9%
1 pts worse
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.2% · Q3 6.7% · Q4 8.7% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.1% |
4.3%
0.2 pts better
|
11.4%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 9.5% · Q3 0.0% · Q4 0.0% · 4Q avg 4.1% |
| Percentage of long-stay residents who lose too much weight | 5.8% |
4.1%
1.7 pts worse
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 7.3% · Q3 5.1% · Q4 5.6% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.5% |
12.4%
0.9 pts better
|
19.6%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 14.6% · Q3 10.3% · Q4 8.3% · 4Q avg 11.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.8% |
17.5%
1.3 pts worse
|
16.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 14.7% · Q3 14.7% · Q4 26.7% · 4Q avg 18.8% · 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 | 32.9% |
22.5%
10.4 pts worse
|
16.3%
16.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 32.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.4% |
18.6%
4.8 pts worse
|
14.9%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 35.1% · Q3 31.4% · Q4 15.2% · 4Q avg 23.4% · 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 3.3% · Q2 5.4% · Q3 1.9% · Q4 3.7% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.7% |
2.6%
0.1 pts worse
|
1.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.2% · Q3 4.4% · Q4 2.2% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.0% |
24.8%
2.2 pts worse
|
19.8%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 31.4% · Q3 24.0% · Q4 28.6% · 4Q avg 27.0% |
| Percentage of long-stay residents with pressure ulcers | 12.1% |
5.4%
6.7 pts worse
|
5.1%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 16.0% · Q3 14.0% · Q4 6.1% · 4Q avg 12.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.0% |
88.6%
6.4 pts better
|
81.7%
13.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.2% · Q2 96.9% · Q3 97.3% · Q4 93.5% · 4Q avg 95.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.2% |
14.0%
5.8 pts better
|
12.0%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.2% · Observed 7.5% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.9%
0.2 pts better
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 2.0% · Q4 2.2% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.4% |
82.7%
3.7 pts better
|
79.7%
6.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.3% |
23.1%
0.2 pts worse
|
23.9%
0.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.3% · Observed 17.5% · Expected 17.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-25 · Fire 2024-04-25
6 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-08-24 · Fire 2023-08-24
3 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
6 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-08-24
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.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-24
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-09-28
F · Potential for more than minimal harm
2023-08-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-08-24
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 2023-09-28
D · Potential for more than minimal harm
2023-08-24
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-09-28
C · Minimal harm
2023-08-24
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2023-09-28
Inspection history
Recent health citations
J · Immediate jeopardy
2024-04-25
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 2024-05-17
F · Potential for more than minimal harm
2024-04-25
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 2024-05-17
D · Potential for more than minimal harm
2024-04-25
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 2024-05-17
D · Potential for more than minimal harm
2024-04-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-25
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-05-17
C · Minimal harm
2024-04-25
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-05-17
D · Potential for more than minimal harm
2023-08-24
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-08-24
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-08-24
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 2023-09-28
Penalties and ownership
What sits behind the stars
$8,827
2024-04-25
Fine
Fine · fine $8,827
Fine
Ownership
Presbyterian Homes Housing And Assisted Living, Inc.
5% Or Greater Direct Ownership Interest · Organization
Fletcher, Jonathan
Corporate Director · Individual
Fletcher, Jonathan
Corporate Officer · Individual
Meyer, Mark
Corporate Director · Individual
Meyer, Mark
Corporate Officer · Individual
Mielke, John
Operational/Managerial Control · Individual
Northeast Bank
5% Or Greater Security Interest · Organization
Northeast Bank
5% Or Greater Mortgage Interest · Organization
Pederson, Mark
Corporate Director · Individual
Phs Management, LLC
Operational/Managerial Control · Organization
Presbyterian Homes Housing And Assisted Living, Inc.
Operational/Managerial Control · Organization
Sokoloski, Shaylee
Operational/Managerial Control · Individual
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