Cycle 1
Health 2025-07-31 · Fire 2025-07-31
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Lake City, MN
Mayo Clinic Health System - Lake City
4-star overall rating with 3-star inspections with $32,139 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
500 West Grant Street, Lake City, MN
(651) 345-1144
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
90
Certified beds
Average residents
57
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1978-03-20
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
1.34
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.81
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
5.06
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
2.25
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.46
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.76
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.42
CMS adjusted RN staffing hours
Adjusted total hours
5.38
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,742
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.82
Composite VBP score used to determine payment impact.
Payment multiplier
0.9867
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
1.63
Baseline 50.00% · Performance 57.00% · Measure score 1.63 · Achievement 1.63 · Improvement 0
Adjusted total nurse staffing
4.73
Baseline 3.42 hours · Performance 4.42 hours · Measure score 4.73 · Achievement 4.73 · Improvement 3.75
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.07% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 7.32% · Lower 95% interval 6.89% |
| Discharge to community | 53.72% |
50.57%
3.1 pts better
|
No Different than the National Rate · Eligible stays 45 · Observed rate 46.67% · Lower 95% interval 38.12% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.62% |
95.27%
2.4 pts better
|
Numerator 41 · Denominator 42 |
| Falls with major injury | 4.76% |
0.77%
4 pts worse
|
Numerator 2 · Denominator 42 |
| Discharge self-care score | 55.17% |
53.69%
1.5 pts better
|
Numerator 16 · Denominator 29 |
| Discharge mobility score | 82.76% |
50.94%
31.8 pts better
|
Numerator 24 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 2.38% |
2.29%
0.1 pts worse
|
Numerator 1 · Denominator 42 · Adjusted rate 2.57% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 4.57% |
8.2%
3.6 pts worse
|
Numerator 9 · Denominator 197 |
| Staff flu vaccination coverage | 13.82% |
42%
28.2 pts worse
|
Numerator 21 · Denominator 152 |
| Discharge function score | 82.76% |
56.45%
26.3 pts better
|
Numerator 24 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 22 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 53.13% |
25.2%
27.9 pts better
|
Numerator 17 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.7
0.3 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.6 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 6.0 |
2.0
4 pts worse
|
1.8
4.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 6.0 · Observed 6.9 · Expected 1.9 · Used in QM five-star |
| 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 | 98.4% |
96.1%
2.3 pts better
|
95.5%
2.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.9%
0.8 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 1.7% · Q3 5.2% · Q4 1.9% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.4% |
4.3%
0.9 pts better
|
11.4%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 4.0% · Q3 3.6% · Q4 2.0% · 4Q avg 3.4% |
| Percentage of long-stay residents who lose too much weight | 9.5% |
4.1%
5.4 pts worse
|
5.4%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 13.5% · Q3 14.9% · Q4 2.2% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.3% |
12.4%
6.9 pts worse
|
19.6%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 19.2% · Q3 20.8% · Q4 19.6% · 4Q avg 19.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.7% |
17.5%
0.2 pts worse
|
16.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 22.2% · Q3 13.6% · Q4 12.2% · 4Q avg 17.7% · 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 | 22.4% |
22.5%
0.1 pts better
|
16.3%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.3% |
18.6%
0.3 pts better
|
14.9%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 15.6% · Q3 16.3% · Q4 16.7% · 4Q avg 18.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
2.3%
0.6 pts better
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.6% · Q3 3.4% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
2.6%
0.4 pts better
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 5.1% · Q3 0.0% · Q4 1.9% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.3% |
24.8%
6.5 pts worse
|
19.8%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 39.4% · Q3 37.7% · Q4 32.2% · 4Q avg 31.3% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
5.4%
1.7 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 4.7% · Q3 2.6% · Q4 4.2% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
88.6%
10.9 pts better
|
81.7%
17.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 25.0% |
14.0%
11 pts worse
|
12.0%
13 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.0% · Observed 25.0% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.7% |
1.9%
1.8 pts worse
|
1.6%
2.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 5.6% · Q4 6.9% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.6% |
82.7%
13.9 pts better
|
79.7%
16.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.3% |
23.1%
5.8 pts better
|
23.9%
6.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.3% · Observed 16.7% · Expected 22.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-13 · Fire 2024-06-13
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2023-07-27 · Fire 2023-07-27
5 health deficiencies
Top issue: Resident Rights (4 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-07-31
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-09-08
F · Potential for more than minimal harm
2024-06-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-31
C · Minimal harm
2024-06-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-31
F · Potential for more than minimal harm
2023-07-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-28
F · Potential for more than minimal harm
2023-07-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-08-28
D · Potential for more than minimal harm
2023-07-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-28
D · Potential for more than minimal harm
2023-07-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-04
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 2025-12-19
D · Potential for more than minimal harm
2025-07-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-08
G · Actual harm
2025-04-03
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 2025-05-01
G · Actual harm
2024-12-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-06-13
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-06-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-06-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-06-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-06-13
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-06-13
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-06-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-06-13
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-08-09
B · Minimal harm
2024-06-13
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-08-09
D · Potential for more than minimal harm
2023-11-06
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-11-27
D · Potential for more than minimal harm
2023-11-06
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 2023-11-27
D · Potential for more than minimal harm
2023-11-06
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 2023-11-27
D · Potential for more than minimal harm
2023-11-06
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-11-27
D · Potential for more than minimal harm
2023-11-06
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2023-11-27
Penalties and ownership
What sits behind the stars
$32,139
2025-04-03
Fine
Fine · fine $32,139
Fine
Ownership
Albright, Robert
Corporate Director · Individual
Anderson, Brett
Operational/Managerial Control · Individual
Anderson, Trent
Corporate Director · Individual
Durand, Kathleen
Corporate Director · Individual
Ebenezer Management Services Inc
Operational/Managerial Control · Organization
Flattum, Bethanie
Corporate Director · Individual
Flattum, Bethanie
Corporate Officer · Individual
Foss, Randy
Operational/Managerial Control · Individual
Foss, Randy
Corporate Director · Individual
Foss, Randy
Corporate Officer · Individual
Gulden, Christopher
Corporate Officer · Individual
Harnisch, Mackenzie
Operational/Managerial Control · Individual
Mayo Clinic
Operational/Managerial Control · Organization
Mcgrath, Cindy
Corporate Director · Individual
Miller, Morris
Corporate Officer · Individual
Robelia, Paul
Corporate Director · Individual
Sexton Oliver, Tracy
Corporate Director · Individual
Smith, Joshua
Corporate Director · Individual
Willett, Todd
Operational/Managerial Control · Individual
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#2
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3-star overall rating with 4-star inspections with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
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