Cycle 1
Health 2025-06-12 · Fire 2025-06-12
4 health deficiencies
Top issue: Infection Control (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Rochester, MN
Madonna Towers Of Rochester Inc
3-star overall rating with 3-star inspections with $10,196 in total fines with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
4001 19th Avenue Northwest, Rochester, MN
(507) 206-2222
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
62
Certified beds
Average residents
54
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Benedictine Health System
Operator or chain grouping
Approved since
1968-03-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
22 facilities
Chain averages 3 overall / 3 health / 4 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
1.22
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.54
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.48
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.25
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.76
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.62
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.77
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.40
CMS adjusted RN staffing hours
Adjusted total hours
4.86
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,794
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.54
Composite VBP score used to determine payment impact.
Payment multiplier
0.9916
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.28
Baseline 22.41% · Performance 20.38% · Measure score 3.28 · Achievement 2.28 · Improvement 3.28
Healthcare-associated infections
6.36
Baseline 5.24% · Performance 5.93% · Measure score 6.36 · Achievement 6.36 · Improvement 0
Total nurse turnover
1.31
Baseline 67.78% · Performance 60.00% · Measure score 1.31 · Achievement 0.9 · Improvement 1.31
Adjusted total nurse staffing
4.46
Baseline 4.05 hours · Performance 4.35 hours · Measure score 4.46 · Achievement 4.46 · Improvement 1.22
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.38% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 210 · Observed rate 7.14% · Lower 95% interval 7.14% |
| Discharge to community | 52.03% |
50.57%
1.5 pts better
|
No Different than the National Rate · Eligible stays 218 · Observed rate 48.17% · Lower 95% interval 44.91% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 122 · Denominator 122 |
| Falls with major injury | 2.46% |
0.77%
1.7 pts worse
|
Numerator 3 · Denominator 122 |
| Discharge self-care score | 51.04% |
53.69%
2.6 pts worse
|
Numerator 49 · Denominator 96 |
| Discharge mobility score | 42.71% |
50.94%
8.2 pts worse
|
Numerator 41 · Denominator 96 |
| Pressure ulcers or injuries, new or worsened | 1.64% |
2.29%
0.7 pts better
|
Numerator 2 · Denominator 122 · Adjusted rate 2.27% |
| Healthcare-associated infections requiring hospitalization | 5.93% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 126 · Observed rate 3.97% · Lower 95% interval 3.88% |
| Staff COVID-19 vaccination coverage | 1.75% |
8.2%
6.4 pts worse
|
Numerator 2 · Denominator 114 |
| Staff flu vaccination coverage | 32.76% |
42%
9.2 pts worse
|
Numerator 38 · Denominator 116 |
| Discharge function score | 57.29% |
56.45%
0.8 pts better
|
Numerator 55 · Denominator 96 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 25 · Denominator 25 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 68 · Denominator 68 |
| Resident COVID-19 vaccinations up to date | 58.18% |
25.2%
33 pts better
|
Numerator 32 · Denominator 55 |
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 | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 10.2% |
3.9%
6.3 pts worse
|
3.3%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 9.5% · Q3 8.1% · Q4 14.0% · 4Q avg 10.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.8% |
4.3%
0.5 pts better
|
11.4%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 0.0% · Q3 5.4% · Q4 2.5% · 4Q avg 3.8% |
| Percentage of long-stay residents who lose too much weight | 9.6% |
4.1%
5.5 pts worse
|
5.4%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 12.1% · Q3 9.7% · Q4 8.8% · 4Q avg 9.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.0% |
12.4%
4.4 pts better
|
19.6%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 5.9% · Q3 9.4% · Q4 5.9% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.5% |
17.5%
10 pts better
|
16.7%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 7.7% · Q3 3.8% · Q4 4.2% · 4Q avg 7.5% · 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 | 20.4% |
22.5%
2.1 pts better
|
16.3%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.2% |
18.6%
7.4 pts better
|
14.9%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 2.9% · Q3 12.9% · Q4 6.2% · 4Q avg 11.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.8% |
2.3%
0.5 pts worse
|
1.0%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 4.1% · Q3 0.0% · Q4 3.2% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.9% |
2.6%
2.3 pts worse
|
1.7%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 7.3% · Q3 2.8% · Q4 7.0% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.6% |
24.8%
1.2 pts better
|
19.8%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.0% · Q2 20.6% · Q3 19.6% · Q4 21.4% · 4Q avg 23.6% |
| Percentage of long-stay residents with pressure ulcers | 10.7% |
5.4%
5.3 pts worse
|
5.1%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 11.9% · Q3 12.5% · Q4 8.8% · 4Q avg 10.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
88.6%
9.4 pts better
|
81.7%
16.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 100.0% · Q3 97.5% · Q4 96.4% · 4Q avg 98.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.1% |
14.0%
2.9 pts better
|
12.0%
0.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.1% · Observed 9.4% · Expected 9.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.9%
About the same
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.5% · Q3 1.2% · Q4 1.2% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.3% |
82.7%
10.6 pts better
|
79.7%
13.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.9% |
23.1%
6.8 pts worse
|
23.9%
6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.9% · Observed 24.5% · Expected 19.6% · 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: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2023-05-25 · Fire 2023-05-25
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-07-15
F · Potential for more than minimal harm
2025-06-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-07-15
F · Potential for more than minimal harm
2025-06-12
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.
Corrected 2025-07-15
F · Potential for more than minimal harm
2025-06-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-15
C · Minimal harm
2025-06-12
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-07-15
C · Minimal harm
2025-06-12
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-07-15
F · Potential for more than minimal harm
2024-04-25
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-05-31
F · Potential for more than minimal harm
2024-04-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-24
F · Potential for more than minimal harm
2024-04-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-31
F · Potential for more than minimal harm
2024-04-25
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-05-31
F · Potential for more than minimal harm
2024-04-25
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.
Corrected 2024-05-08
F · Potential for more than minimal harm
2024-04-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-04-24
E · Potential for more than minimal harm
2024-04-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-24
F · Potential for more than minimal harm
2023-05-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-30
C · Minimal harm
2023-05-25
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-06-30
C · Minimal harm
2023-05-25
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-06-30
C · Minimal harm
2023-05-25
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-06-30
C · Minimal harm
2023-05-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-30
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-06-12
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 2025-07-15
D · Potential for more than minimal harm
2025-06-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-06-12
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-07-15
C · Minimal harm
2025-06-12
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-02-12
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-02-12
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 2025-03-20
D · Potential for more than minimal harm
2025-02-12
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 2025-03-20
J · Immediate jeopardy
2024-08-26
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 2024-08-16
F · Potential for more than minimal harm
2024-08-26
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-08-26
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 2024-10-01
D · Potential for more than minimal harm
2024-01-30
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 2024-02-27
E · Potential for more than minimal harm
2023-12-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-15
B · Minimal harm
2023-12-28
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-06-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-05-25
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-05-25
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-07-14
Penalties and ownership
What sits behind the stars
$10,196
2024-08-26
Fine
Fine · fine $10,196
Fine
Ownership
Benedictine Health System
5% Or Greater Direct Ownership Interest · Organization
Anderson, Justin
Corporate Director · Individual
Bakke, Christine
Contracted Managing Employee · Individual
Benedictine Health System
Operational/Managerial Control · Organization
Bergien, Tricia
Corporate Officer · Individual
Boldt, Christine
Corporate Director · Individual
Carley, Gerald
Operational/Managerial Control · Individual
Eustice, Diane
Corporate Director · Individual
Geisler, Timothy
Corporate Director · Individual
Graham, Barbara
Corporate Director · Individual
Koshire, Larry
Corporate Director · Individual
Obrien, Michael
Corporate Director · Individual
Russell, James
Corporate Director · Individual
Rymanowski, Kevin
Corporate Officer · Individual
Schwinghammer, Diane
Corporate Director · Individual
Snyder, Bruce
Corporate Director · Individual
Trueman, Barbara
Corporate Director · Individual
Willard, Michael
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Edenbrook Rochester West
Rochester, MN
2-star overall rating with 1-star inspections with $14,518 in total fines with 12 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#2
Rochester Rehabilitation And Living Center
Rochester, MN
1-star overall rating with 1-star inspections with Special Focus status with 17 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Edenbrook Of Rochester
Rochester, MN
2-star overall rating with 2-star inspections with $56,756 in total fines with 11 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
Jump out