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
Staffing
Hours and turnover
RN hours / resident day
1.22
Registered nurse staffing
LPN hours / resident day
0.54
Licensed practical nurse staffing
Aide hours / resident day
2.48
Nurse aide staffing
Weekend hours
3.62
Weekend nurse staffing
RN turnover
50%
Annual RN turnover
Total nurse turnover
56%
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 | 100.0% |
97.3%
2.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 | 20.4% |
22.5%
2.1 pts better
|
16.3%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
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