Cycle 1
Health 2025-12-18 · Fire 2025-12-18
7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Milaca, MN
Milaca Elim Meadows Health Care Center
4-star overall rating with 4-star inspections with 7 recent health deficiencies
730 Second Street Southeast, Milaca, MN
(320) 983-2185
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
58
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Cassia
Operator or chain grouping
Approved since
1987-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
16 facilities
Chain averages 5 overall / 4 health / 5 staffing / 4 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
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
518
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
68.39
Composite VBP score used to determine payment impact.
Payment multiplier
1.0215
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.28
Baseline 17.89% · Performance 18.06% · Measure score 7.28 · Achievement 7.28 · Improvement 0
Healthcare-associated infections
5.77
Baseline 5.67% · Performance 6.11% · Measure score 5.77 · Achievement 5.77 · Improvement 0
Total nurse turnover
8.21
Baseline 23.88% · Performance 30.14% · Measure score 8.21 · Achievement 8.21 · Improvement 0
Adjusted total nurse staffing
6.10
Baseline 4.47 hours · Performance 4.81 hours · Measure score 6.10 · Achievement 6.10 · Improvement 2.12
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.37% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 71 · Observed rate 7.04% · Lower 95% interval 6.44% |
| Discharge to community | 69.38% |
50.57%
18.8 pts better
|
Better than the National Rate · Eligible stays 66 · Observed rate 65.15% · Lower 95% interval 57.7% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.57% |
95.27%
3.3 pts better
|
Numerator 69 · Denominator 70 |
| Falls with major injury | 1.43% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 70 |
| Discharge self-care score | 73.68% |
53.69%
20 pts better
|
Numerator 42 · Denominator 57 |
| Discharge mobility score | 92.98% |
50.94%
42 pts better
|
Numerator 53 · Denominator 57 |
| Pressure ulcers or injuries, new or worsened | 4.29% |
2.29%
2 pts worse
|
Numerator 3 · Denominator 70 · Adjusted rate 6.41% |
| Healthcare-associated infections requiring hospitalization | 6.11% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 28 · Observed rate 0% · Lower 95% interval 3.2% |
| Staff COVID-19 vaccination coverage | 3.87% |
8.2%
4.3 pts worse
|
Numerator 6 · Denominator 155 |
| Staff flu vaccination coverage | 13.07% |
42%
28.9 pts worse
|
Numerator 20 · Denominator 153 |
| Discharge function score | 91.23% |
56.45%
34.8 pts better
|
Numerator 52 · Denominator 57 |
| Transfer of health information to provider | 86.84% |
95.95%
9.1 pts worse
|
Numerator 33 · Denominator 38 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 22 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 50% |
25.2%
24.8 pts better
|
Numerator 17 · Denominator 34 |
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 | 2.7% |
3.9%
1.2 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 4.1% · Q3 2.2% · Q4 2.4% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
4.3%
3.2 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.3% · Q4 2.6% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 4.5% |
4.1%
0.4 pts worse
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 5.7% · Q3 2.9% · Q4 3.7% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.8% |
12.4%
5.6 pts better
|
19.6%
12.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 8.6% · Q3 5.7% · Q4 3.7% · 4Q avg 6.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.0% |
17.5%
4.5 pts better
|
16.7%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 9.7% · Q3 12.0% · Q4 21.7% · 4Q avg 13.0% · 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 | 18.6% |
22.5%
3.9 pts better
|
16.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 21.5% · Q3 20.3% · 4Q avg 18.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.1% |
18.6%
3.5 pts better
|
14.9%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 15.6% · Q3 18.2% · Q4 21.7% · 4Q avg 15.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
2.3%
1.2 pts better
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 2.7% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
2.6%
1.5 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 0.0% · Q4 2.4% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.9% |
24.8%
1.1 pts worse
|
19.8%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 17.4% · Q3 30.2% · Q4 27.3% · 4Q avg 25.9% |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
5.4%
2 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.5% · Q3 3.8% · Q4 3.2% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
88.6%
8.4 pts better
|
81.7%
15.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.6% · Q2 97.8% · Q3 96.7% · Q4 96.0% · 4Q avg 97.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.2% |
14.0%
3.8 pts better
|
12.0%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.2% · Observed 9.1% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.9%
1 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 1.5% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.8% |
82.7%
15.1 pts better
|
79.7%
18.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.7% |
23.1%
2.4 pts better
|
23.9%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.7% · Observed 18.2% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2025-01-09 · Fire 2025-01-09
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-11-29 · Fire 2023-11-29
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-11-29
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-02-01
F · Potential for more than minimal harm
2023-11-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-05
F · Potential for more than minimal harm
2023-11-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-05
F · Potential for more than minimal harm
2023-11-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-01-05
F · Potential for more than minimal harm
2023-11-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-11-29
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Not marked corrected
E · Potential for more than minimal harm
2023-11-29
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 2023-12-04
E · Potential for more than minimal harm
2023-11-29
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-29
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-11-29
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 2023-12-12
E · Potential for more than minimal harm
2023-11-29
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-02-01
E · Potential for more than minimal harm
2023-11-29
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-11-27
E · Potential for more than minimal harm
2023-11-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-12-14
E · Potential for more than minimal harm
2023-11-29
K930 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper storage of liquid oxygen.
Corrected 2023-12-22
C · Minimal harm
2023-11-29
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-12-29
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-18
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2026-01-09
D · Potential for more than minimal harm
2025-12-18
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2026-01-09
D · Potential for more than minimal harm
2025-12-18
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2026-01-09
D · Potential for more than minimal harm
2025-12-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-01-09
D · Potential for more than minimal harm
2025-12-18
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 2026-01-09
D · Potential for more than minimal harm
2025-12-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-09
C · Minimal harm
2025-12-18
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-01-09
D · Potential for more than minimal harm
2025-01-09
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 2025-01-25
D · Potential for more than minimal harm
2023-11-29
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-11-29
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 2023-12-29
D · Potential for more than minimal harm
2023-11-29
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-06-22
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-08-02
D · Potential for more than minimal harm
2023-06-22
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-08-02
Penalties and ownership
What sits behind the stars
Ownership
Elim Care Inc
5% Or Greater Direct Ownership Interest · Organization
Broberg, Laura
W-2 Managing Employee · Individual
Cassia
Operational/Managerial Control · Organization
Dahl, Robert
Corporate Officer · Individual
Kern, Matthew
Corporate Officer · Individual
Leff, William
Corporate Director · Individual
Nye, Gerald
Corporate Director · Individual
Peterson, Roland
Corporate Director · Individual
Tangedahl, Guy
Corporate Director · Individual
Youngquist, Kathryn
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Elim Wellspring
Princeton, MN
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
The Gardens at Foley LLC
Foley, MN
3-star overall rating with 3-star inspections with $8,824 in total fines with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
St Clare Living Community Of Mora
Mora, MN
4-star overall rating with 3-star inspections with $45,100 in total fines with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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