Cycle 1
Health 2025-03-12 · Fire 2025-03-12
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Plymouth, MN
Mission Nursing Home
3-star overall rating with 2-star inspections with 10 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
3401 East Medicine Lake Boulevard, Plymouth, MN
(763) 231-5924
Overall
3 / 5
CMS overall stars
Health inspections
2 / 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
70
Certified beds
Average residents
56
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1991-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.41
Registered nurse staffing
LPN hours / resident day
0.33
Licensed practical nurse staffing
Aide hours / resident day
2.65
Nurse aide staffing
Weekend hours
3.67
Weekend nurse staffing
RN turnover
56%
Annual RN turnover
Total nurse turnover
44%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.2 |
1.7
1.5 pts worse
|
1.9
1.3 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
2.0
0.2 pts better
|
1.8
About the same
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
97.3%
2.2 pts better
|
93.4%
6.1 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 | 1.0% |
3.9%
2.9 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 14.1% |
4.3%
9.8 pts worse
|
11.4%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 5.6% |
4.1%
1.5 pts worse
|
5.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.9% |
12.4%
6.5 pts worse
|
19.6%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 22.8% |
17.5%
5.3 pts worse
|
16.7%
6.1 pts worse
|
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 | 11.5% |
22.5%
11 pts better
|
16.3%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.7% |
18.6%
7.9 pts better
|
14.9%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
2.6%
0.2 pts better
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.3% |
24.8%
2.5 pts worse
|
19.8%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
5.4%
0.8 pts worse
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.3% |
88.6%
11.3 pts worse
|
81.7%
4.4 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
1.9%
0.9 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.7% |
82.7%
4 pts better
|
79.7%
7 pts better
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-31 · Fire 2024-05-31
15 health deficiencies
Top issue: Resident Rights (6 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2023-07-12 · Fire 2023-07-12
3 health deficiencies
Top issue: Infection Control (2 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-21
F · Potential for more than minimal harm
2025-03-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-04-04
F · Potential for more than minimal harm
2025-03-12
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-03-21
F · Potential for more than minimal harm
2025-03-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-21
F · Potential for more than minimal harm
2025-03-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-04
E · Potential for more than minimal harm
2025-03-12
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-04-30
E · Potential for more than minimal harm
2025-03-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-30
E · Potential for more than minimal harm
2025-03-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-12
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 2025-03-21
D · Potential for more than minimal harm
2025-03-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-21
F · Potential for more than minimal harm
2024-05-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-20
F · Potential for more than minimal harm
2024-05-31
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-06-20
F · Potential for more than minimal harm
2024-05-31
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-06-20
F · Potential for more than minimal harm
2024-05-31
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-06-20
E · Potential for more than minimal harm
2024-05-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-28
E · Potential for more than minimal harm
2024-05-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-05-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-05-31
K930 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper storage of liquid oxygen.
Corrected 2024-06-20
C · Minimal harm
2024-05-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-20
F · Potential for more than minimal harm
2023-07-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-29
F · Potential for more than minimal harm
2023-07-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-07-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-09-29
F · Potential for more than minimal harm
2023-07-12
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2023-09-29
F · Potential for more than minimal harm
2023-07-12
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 2023-10-04
F · Potential for more than minimal harm
2023-07-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-28
E · Potential for more than minimal harm
2023-07-12
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Not marked corrected
E · Potential for more than minimal harm
2023-07-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-09-25
E · Potential for more than minimal harm
2023-07-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-07-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-07-12
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 2023-09-28
D · Potential for more than minimal harm
2023-07-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-07-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-05
D · Potential for more than minimal harm
2023-07-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-29
C · Minimal harm
2023-07-12
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-08-18
C · Minimal harm
2023-07-12
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-08-18
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-08
F729 · Nursing and Physician Services Deficiencies
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected 2026-01-23
D · Potential for more than minimal harm
2025-07-03
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-07-03
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-07-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-18
G · Actual harm
2025-04-10
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-04-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-10
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 2025-05-09
F · Potential for more than minimal harm
2025-03-12
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-04-18
E · Potential for more than minimal harm
2025-03-12
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 2025-04-18
D · Potential for more than minimal harm
2025-03-12
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-04-18
F · Potential for more than minimal harm
2024-05-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-12
F · Potential for more than minimal harm
2024-05-31
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-05-31
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-05-31
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-05-31
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-05-31
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-05-31
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 2024-07-12
D · Potential for more than minimal harm
2024-05-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-05-31
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-05-31
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 2024-07-12
D · Potential for more than minimal harm
2024-05-31
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-05-31
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-05-31
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 2024-07-12
D · Potential for more than minimal harm
2024-05-31
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-04-24
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-05-17
F · Potential for more than minimal harm
2023-12-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-12-13
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-07-12
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-08-28
Penalties and ownership
What sits behind the stars
Ownership
Missions, Inc Programs
5% Or Greater Direct Ownership Interest · Organization
Aurand, Claudia
Corporate Director · Individual
Barker, Joel
Corporate Director · Individual
Billy, Stacey
Corporate Director · Individual
Bobo, Cynthia
Corporate Director · Individual
Collins, Lucas
Operational/Managerial Control · Individual
Daniels, Kathryn
Corporate Director · Individual
Determan, Teresa
Corporate Director · Individual
Fallon, Tamara
Corporate Director · Individual
Kiwus, Kelly
Corporate Director · Individual
Mannix, Peter
Corporate Director · Individual
Meyer, Ellen
Corporate Director · Individual
Missions, Inc Programs
Operational/Managerial Control · Organization
Missions, Inc Programs
5% Or Greater Security Interest · Organization
Moncrief, William
Operational/Managerial Control · Individual
Moncrief, William
Corporate Director · Individual
Nettles, Andrea
Corporate Director · Individual
O'brien, Linda
Operational/Managerial Control · Individual
Rodriguez, Jennifer
Operational/Managerial Control · Individual
Senkbeil, Mary
Corporate Director · Individual
Sonntag, Robert
Operational/Managerial Control · Individual
Sonntag, Robert
Corporate Director · Individual
Spaulding, Wendy
Corporate Director · Individual
Whitman, Andrew
Corporate Director · Individual
Wold, Dennis
Corporate Director · Individual
Nearby options
Other facilities in reach
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5-star overall rating with 3-star inspections with 3 recent health deficiencies
#2
Good Samaritan Ambassador
New Hope, MN
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
North Ridge Health And Rehab
New Hope, MN
1-star overall rating with 1-star inspections with Special Focus status with $25,480 in total fines with 30 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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