Cycle 1
Health 2025-12-10 · Fire 2025-12-10
3 health deficiencies
Top issue: Resident Rights (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cottage Grove, MN
Norris Square
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
6993 80th Street South, Cottage Grove, MN
(651) 769-6650
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
40
Certified beds
Average residents
34
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Presbyterian Homes & Services
Operator or chain grouping
Approved since
2019-05-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 4 overall / 3 health / 5 staffing / 3 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
1.60
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.02
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
3.03
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.64
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.62
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.27
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
1.28
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.21
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.76
CMS adjusted RN staffing hours
Adjusted total hours
5.12
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
766
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
64.07
Composite VBP score used to determine payment impact.
Payment multiplier
1.0186
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
5.09
Baseline 49.21% · Performance 42.86% · Measure score 5.09 · Achievement 5.09 · Improvement 2.11
Adjusted total nurse staffing
7.72
Baseline 5.03 hours · Performance 5.27 hours · Measure score 7.72 · Achievement 7.72 · Improvement 2.77
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 16 · 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 13 · 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 19 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 19 · 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 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 2.88% |
8.2%
5.3 pts worse
|
Numerator 6 · Denominator 208 |
| Staff flu vaccination coverage | 9.25% |
42%
32.8 pts worse
|
Numerator 21 · Denominator 227 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.1% |
97.3%
2.2 pts worse
|
93.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.6% · Q2 96.4% · Q3 97.1% · Q4 90.6% · 4Q avg 95.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.7% |
96.1%
9.4 pts worse
|
95.5%
8.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.9%
3.9 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.2% |
4.3%
0.9 pts worse
|
11.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.3% · Q3 9.4% · Q4 3.3% · 4Q avg 5.2% |
| Percentage of long-stay residents who lose too much weight | 5.1% |
4.1%
1 pts worse
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 9.5% · Q4 0.0% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.5% |
12.4%
0.9 pts better
|
19.6%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 14.3% · Q4 14.3% · 4Q avg 11.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.9% |
17.5%
6.6 pts better
|
16.7%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.9% · 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 need for help with daily activities has increased | 14.3% |
18.6%
4.3 pts better
|
14.9%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 19.0% · Q4 14.3% · 4Q avg 14.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.6% |
2.3%
2.3 pts worse
|
1.0%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 7.1% · Q3 4.6% · Q4 4.1% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
2.6%
1 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 0.0% · Q4 3.1% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.9% |
24.8%
3.1 pts worse
|
19.8%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.9% · Q2 46.0% · Q3 19.1% · Q4 23.6% · 4Q avg 27.9% |
| Percentage of long-stay residents with pressure ulcers | 7.4% |
5.4%
2 pts worse
|
5.1%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 8.3% · Q3 7.8% · Q4 8.1% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.4% |
88.6%
3.8 pts better
|
81.7%
10.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.8% · Q2 87.8% · Q3 95.0% · Q4 100.0% · 4Q avg 92.4% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.8% |
82.7%
5.1 pts better
|
79.7%
8.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.8% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-24 · Fire 2024-10-24
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-11-03 · Fire 2023-11-03
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2026-02-02
F · Potential for more than minimal harm
2025-12-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-02-02
F · Potential for more than minimal harm
2024-10-24
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 2025-01-02
F · Potential for more than minimal harm
2024-10-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-03
F · Potential for more than minimal harm
2024-10-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-03
F · Potential for more than minimal harm
2023-11-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-03
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-03
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 2023-12-15
F · Potential for more than minimal harm
2023-11-03
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-10
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2026-01-30
D · Potential for more than minimal harm
2025-12-10
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 2026-01-30
D · Potential for more than minimal harm
2025-12-10
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2026-01-30
D · Potential for more than minimal harm
2024-10-24
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 2024-11-20
D · Potential for more than minimal harm
2024-10-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-20
G · Actual harm
2023-11-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-11-03
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-11-03
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-11-03
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-11-03
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-11-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-11-03
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 2023-11-28
D · Potential for more than minimal harm
2023-11-03
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-11-28
Penalties and ownership
What sits behind the stars
$0
2023-11-03
Payment Denial
Payment Denial · denial start 2023-11-29 · 16 days
16 day denial
Ownership
Presbyterian Homes And Services
5% Or Greater Direct Ownership Interest · Organization
Fletcher, Jonathan
Corporate Director · Individual
Fletcher, Jonathan
Corporate Officer · Individual
Kispert, Christopher
Operational/Managerial Control · Individual
Meyer, Mark
Corporate Director · Individual
Meyer, Mark
Corporate Officer · Individual
Mielke, John
Operational/Managerial Control · Individual
Pederson, Mark
Corporate Director · Individual
Phs Management, LLC
Operational/Managerial Control · Organization
Presbyterian Homes Housing And Assisted Living, Inc.
Operational/Managerial Control · Organization
Tcf Investments Management, Inc.
5% Or Greater Security Interest · Organization
Tcf Investments Management, Inc.
5% Or Greater Mortgage Interest · Organization
Nearby options
Other facilities in reach
#1
St Therese Of Woodbury Llc
Woodbury, MN
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Woodbury Health Care Center
Woodbury, MN
1-star overall rating with 1-star inspections with $26,685 in total fines with 12 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#3
Woodlyn Heights Healthcare Center
Inver Grove Heights, MN
1-star overall rating with 1-star inspections with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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