10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Plymouth, MN
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
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
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
RN hours / resident day
1.41
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.33
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.65
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.39
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.74
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.67
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
1.04
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.59
CMS adjusted RN staffing hours
Adjusted total hours
4.93
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 42% · national 46%
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 11 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 9.68% |
8.2%
1.5 pts better
|
Numerator 9 · Denominator 93 |
| Staff flu vaccination coverage | 68.82% |
42%
26.8 pts better
|
Numerator 64 · Denominator 93 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
Quality measures
| 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 · Adjusted 3.2 · Observed 5.1 · Expected 3.0 · Used in QM five-star |
| 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 · Adjusted 1.8 · Observed 2.2 · Expected 2.0 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 98.2% · Q3 100.0% · Q4 100.0% · 4Q avg 99.5% |
| 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 | 1.0% |
3.9%
2.9 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| 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 · Q1 15.8% · Q2 21.1% · Q3 2.7% · Q4 16.7% · 4Q avg 14.1% |
| 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 · Q1 2.0% · Q2 13.0% · Q3 4.7% · Q4 2.5% · 4Q avg 5.6% |
| 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 · Q1 26.0% · Q2 17.0% · Q3 18.6% · Q4 12.5% · 4Q avg 18.9% |
| 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 · Q1 34.4% · Q2 28.0% · Q3 13.8% · Q4 14.3% · 4Q avg 22.8% · 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 | 11.5% |
22.5%
11 pts better
|
16.3%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.5% · Used in QM five-star |
| 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 · Q1 8.5% · Q2 18.2% · Q3 8.6% · Q4 6.1% · 4Q avg 10.7% · 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 1.4% · Q2 0.0% · Q3 1.4% · Q4 4.5% · 4Q avg 1.7% · Used in QM five-star |
| 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 · Q1 1.8% · Q2 1.8% · Q3 0.0% · Q4 6.2% · 4Q avg 2.4% · Used in QM five-star |
| 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 · Q1 29.9% · Q2 38.3% · Q3 18.9% · Q4 20.6% · 4Q avg 27.3% |
| 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 · Q1 8.2% · Q2 6.4% · Q3 5.3% · Q4 4.5% · 4Q avg 6.2% · Used in QM five-star |
| 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 · Q1 69.2% · Q2 82.8% · Q3 81.8% · Q4 75.0% · 4Q avg 77.3% |
| 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 · 4Q avg 2.8% · Used in QM five-star |
| 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 · 4Q avg 86.7% |
Survey summary
Top issue: Quality of Life and Care (3 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Resident Rights (6 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Infection Control (2 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-21
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-04-04
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-03-21
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-21
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-04
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-04-30
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-30
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-04
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
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-21
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-20
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-06-20
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-06-20
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-06-20
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-28
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-20
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-06-20
Fire Safety
Ensure proper storage of liquid oxygen.
Corrected 2024-06-20
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-20
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-29
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-27
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-09-29
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2023-09-29
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
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-28
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Not marked corrected
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-09-25
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-09-25
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-09-28
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
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-25
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-05
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-29
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-08-18
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-08-18
Inspection history
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
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-08-18
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-08-18
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-18
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-04-03
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-05-09
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-09
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-04-18
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-18
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-04-18
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-12
Health
Implement a program that monitors antibiotic use.
Corrected 2024-07-12
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-07-12
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-07-12
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
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
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
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-12
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-12
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-12
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-07-12
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-07-12
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
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-07-12
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-05-17
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-04
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-01-04
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
5% Or Greater Direct Ownership Interest · Organization
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
5% Or Greater Security Interest · Organization
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Nearby options
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5-star overall rating with 3-star inspections with 3 recent health deficiencies
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5-star overall rating with 5-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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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