Cycle 1
Health 2026-01-27 · Fire 2026-01-27
8 health deficiencies
Top issue: Resident Rights (4 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Madison, MN
Madison Healthcare Services
3-star overall rating with 4-star inspections with $10,036 in total fines with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
900 Second Avenue, Madison, MN
(320) 598-7536
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
51
Certified beds
Average residents
44
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1986-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.12
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.20
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.32
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
0.32
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
0.38
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.16
CMS adjusted RN staffing hours
Adjusted total hours
0.41
CMS adjusted total nurse staffing hours
Case-mix index
1.04
Higher values indicate more complex resident acuity
RN turnover
78%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
94%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,717
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.49
Composite VBP score used to determine payment impact.
Payment multiplier
1.0094
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
4.94
Baseline 55.17% · Performance 43.48% · Measure score 4.94 · Achievement 4.94 · Improvement 3.36
Adjusted total nurse staffing
5.96
Baseline 4.46 hours · Performance 4.77 hours · Measure score 5.96 · Achievement 5.96 · Improvement 1.85
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 17 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 9 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.02% |
8.2%
7.2 pts worse
|
Numerator 1 · Denominator 98 |
| Staff flu vaccination coverage | 58.62% |
42%
16.6 pts better
|
Numerator 102 · Denominator 174 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
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 | 98.0% |
96.1%
1.9 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 9.8% |
3.9%
5.9 pts worse
|
3.3%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 6.4% · Q3 11.4% · Q4 14.0% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
4.3%
3.7 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 6.7% |
4.1%
2.6 pts worse
|
5.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 7.0% · Q3 11.6% · Q4 2.6% · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.2% |
12.4%
0.2 pts better
|
19.6%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 11.4% · Q3 11.6% · Q4 10.3% · 4Q avg 12.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.6% |
17.5%
2.9 pts better
|
16.7%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 15.0% · Q3 14.3% · Q4 11.8% · 4Q avg 14.6% · 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 | 22.0% |
22.5%
0.5 pts better
|
16.3%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.2% · Q2 25.8% · Q3 13.9% · Q4 23.4% · 4Q avg 22.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.0% |
18.6%
2.4 pts worse
|
14.9%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 16.7% · Q3 23.8% · Q4 21.1% · 4Q avg 21.0% · 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 | 1.7% |
2.6%
0.9 pts better
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.2% · Q3 0.0% · Q4 2.3% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.7% |
24.8%
6.1 pts better
|
19.8%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 23.4% · Q3 16.7% · Q4 12.8% · 4Q avg 18.7% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
5.4%
0.1 pts worse
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 7.6% · Q3 4.2% · Q4 6.2% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
88.6%
9.7 pts better
|
81.7%
16.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.5% · 4Q avg 98.3% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-06 · Fire 2024-11-06
3 health deficiencies
Top issue: Administration (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2024-02-28 · Fire 2024-02-28
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-01-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-01-28
E · Potential for more than minimal harm
2026-01-27
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2026-02-03
D · Potential for more than minimal harm
2026-01-27
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 2026-02-03
D · Potential for more than minimal harm
2026-01-27
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2026-02-24
D · Potential for more than minimal harm
2026-01-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2026-02-02
E · Potential for more than minimal harm
2024-11-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-02-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-27
C · Minimal harm
2024-02-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Not marked corrected
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-27
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2026-02-06
D · Potential for more than minimal harm
2026-01-27
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2026-02-06
D · Potential for more than minimal harm
2026-01-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-02-06
D · Potential for more than minimal harm
2026-01-16
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 2026-02-09
D · Potential for more than minimal harm
2026-01-16
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2026-02-09
D · Potential for more than minimal harm
2025-06-04
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-07-11
D · Potential for more than minimal harm
2025-06-04
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-07-11
D · Potential for more than minimal harm
2025-06-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-11
E · Potential for more than minimal harm
2024-11-06
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2024-12-31
D · Potential for more than minimal harm
2024-11-06
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-12-31
D · Potential for more than minimal harm
2024-11-06
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 2024-12-31
J · Immediate jeopardy
2024-02-28
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 2024-03-08
E · Potential for more than minimal harm
2024-02-28
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-28
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-03-19
D · Potential for more than minimal harm
2024-02-28
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-03-19
D · Potential for more than minimal harm
2023-11-17
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 2023-12-26
Penalties and ownership
What sits behind the stars
$10,036
2024-02-28
Fine
Fine · fine $10,036
Fine
Ownership
Bjerke, Erik
W-2 Managing Employee · Individual
Borgerson, Carol
Corporate Officer · Individual
Engebretson, Ramona
W-2 Managing Employee · Individual
Hacker, Brant
W-2 Managing Employee · Individual
Hastad, Trudy
Corporate Director · Individual
Hill, Bart
Corporate Director · Individual
Moen, Karin
Corporate Director · Individual
Munsterman, Jeanene
Corporate Director · Individual
Omland, Scott
Corporate Director · Individual
Volk, Tim
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Johnson Memorial Hosp & Home
Dawson, MN
3-star overall rating with 2-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Appleton Area Health
Appleton, MN
2-star overall rating with 3-star inspections with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Sylvan Court
Canby, MN
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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