13 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Minneapolis, MN
1-star overall rating with 1-star inspections with $136,524 in total fines with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
3720 23rd Avenue South, Minneapolis, MN
(612) 238-2545
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
190
Certified beds
Average residents
146
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Lifespark
Operator or chain grouping
Approved since
1984-05-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
4 facilities
Chain averages 1 overall / 1 health / 3 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
RN hours / resident day
0.72
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.60
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
3.93
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.56
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.66
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.84
CMS adjusted RN staffing hours
Adjusted total hours
4.58
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Program rank
2,495
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.43
Composite VBP score used to determine payment impact.
Payment multiplier
1.0034
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
7.56
Baseline 17.61% · Performance 17.93% · Measure score 7.56 · Achievement 7.56 · Improvement 0
Healthcare-associated infections
3.23
Baseline 5.69% · Performance 6.87% · Measure score 3.23 · Achievement 3.23 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
4.04
Baseline 3.69 hours · Performance 4.23 hours · Measure score 4.04 · Achievement 4.04 · Improvement 2.07
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.35% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 57 · Observed rate 8.77% · Lower 95% interval 6.76% |
| Discharge to community | 49.11% |
50.57%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 42.55% · Lower 95% interval 36.91% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 39 · Denominator 39 |
| Falls with major injury | 2.56% |
0.77%
1.8 pts worse
|
Numerator 1 · Denominator 39 |
| Discharge self-care score | 51.61% |
53.69%
2.1 pts worse
|
Numerator 16 · Denominator 31 |
| Discharge mobility score | 61.29% |
50.94%
10.4 pts better
|
Numerator 19 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 39 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.87% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 5.71% · Lower 95% interval 3.95% |
| Staff COVID-19 vaccination coverage | 7.38% |
8.2%
0.8 pts worse
|
Numerator 11 · Denominator 149 |
| Staff flu vaccination coverage | 36.6% |
42%
5.4 pts worse
|
Numerator 56 · Denominator 153 |
| Discharge function score | 67.74% |
56.45%
11.3 pts better
|
Numerator 21 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 21.74% |
25.2%
3.5 pts worse
|
Numerator 5 · Denominator 23 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.7
0.3 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.7 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.0
0.1 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
97.3%
About the same
|
93.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.6% · Q2 97.0% · Q3 96.6% · Q4 97.9% · 4Q avg 97.3% |
| 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 | 3.1% |
3.9%
0.8 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.8% · Q3 3.4% · Q4 2.1% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.1% |
4.3%
2.2 pts better
|
11.4%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.0% · Q3 1.9% · Q4 3.8% · 4Q avg 2.1% |
| Percentage of long-stay residents who lose too much weight | 4.6% |
4.1%
0.5 pts worse
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 6.1% · Q3 4.7% · Q4 6.5% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.7% |
12.4%
1.7 pts better
|
19.6%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 10.3% · Q3 10.9% · Q4 10.3% · 4Q avg 10.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.0% |
17.5%
7.5 pts worse
|
16.7%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 25.3% · Q3 25.3% · Q4 23.8% · 4Q avg 25.0% · 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 | 18.2% |
22.5%
4.3 pts better
|
16.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 13.0% · Q3 18.3% · Q4 16.4% · 4Q avg 18.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.2% |
18.6%
5.4 pts better
|
14.9%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 15.2% · Q3 16.3% · Q4 10.0% · 4Q avg 13.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
2.3%
1.8 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.7% · Q4 1.2% · 4Q avg 0.5% · 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 1.6% · Q2 3.1% · Q3 2.8% · Q4 2.1% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.7% |
24.8%
4.1 pts better
|
19.8%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 18.1% · Q3 23.4% · Q4 20.3% · 4Q avg 20.7% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
5.4%
2.8 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.8% · Q3 3.4% · Q4 1.9% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.8% |
88.6%
11.8 pts worse
|
81.7%
4.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 71.4% · Q2 74.1% · Q3 76.9% · Q4 88.7% · 4Q avg 76.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.3% |
14.0%
1.7 pts better
|
12.0%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.3% · Observed 13.2% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.9%
1.3 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 66.4% |
82.7%
16.3 pts worse
|
79.7%
13.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 66.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.6% |
23.1%
0.5 pts worse
|
23.9%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.6% · Observed 23.7% · Expected 23.9% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (6 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Top issue: Quality of Life and Care (6 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-03-31
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-31
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-05-13
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 2024-05-13
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-05-13
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-05-13
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-05-13
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-05-13
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-13
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-03-31
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-31
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-31
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-31
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-31
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-03-31
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-31
Inspection history
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2026-02-27
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-09
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-05-15
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-12
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 2025-03-31
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-31
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-31
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-31
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-03-31
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-31
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-03-31
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-31
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-03-31
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-25
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-25
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-05-12
Health
Provide or obtain dental services for each resident.
Corrected 2024-05-12
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-05-12
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-05-12
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-05-12
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-05-12
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-12
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-12
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-05-12
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-05-12
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 2024-05-12
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 2024-05-12
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-05-12
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-19
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-12-01
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-12-01
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-01
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-25
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-08-25
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-31
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-03-31
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-03-31
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 2023-03-31
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-03-31
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-31
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-03-31
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-03-31
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-03-31
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-03-31
Penalties and ownership
Fine · fine $75,459
Fine
Fine · fine $19,140
Fine
Fine · fine $21,801
Fine
Fine · fine $20,124
Fine
5% Or Greater Direct Ownership Interest · Organization
W-2 Managing Employee · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Nearby options
Minneapolis, MN
5-star overall rating with 5-star inspections
Minneapolis, MN
1-star overall rating with 2-star inspections with $8,190 in total fines with 10 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
Minneapolis, MN
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Jump out