Cycle 1
Health 2025-04-22 · Fire 2025-04-22
17 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Rochester, MN
Rochester Rehabilitation And Living Center
1-star overall rating with 1-star inspections with Special Focus status with 17 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1900 Ballington Boulevard Nw, Rochester, MN
(507) 535-2000
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
56
Certified beds
Average residents
29
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Volunteers Of America Senior Living
Operator or chain grouping
Approved since
2015-07-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
4 facilities
Chain averages 3 overall / 2 health / 4 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
1.90
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.81
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
5.71
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
2.90
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.72
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
1.22
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.99
CMS adjusted RN staffing hours
Adjusted total hours
5.98
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
79%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
74%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,101
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.39
Composite VBP score used to determine payment impact.
Payment multiplier
0.9906
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.66
Baseline 17.57% · Performance 20.66% · Measure score 1.66 · Achievement 1.66 · Improvement 0
Healthcare-associated infections
6.06
Baseline 4.35% · Performance 6.02% · Measure score 6.06 · Achievement 6.06 · Improvement 0
Total nurse turnover
0
Baseline 57.50% · Performance 91.86% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
7.24
Baseline 5 hours · Performance 5.14 hours · Measure score 7.24 · Achievement 7.24 · Improvement 1.22
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.61% |
10.72%
2.1 pts better
|
No Different than the National Rate · Eligible stays 329 · Observed rate 6.69% · Lower 95% interval 6.12% |
| Discharge to community | 63.99% |
50.57%
13.4 pts better
|
Better than the National Rate · Eligible stays 342 · Observed rate 61.11% · Lower 95% interval 59.46% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.87% |
95.27%
2.6 pts better
|
Numerator 138 · Denominator 141 |
| Falls with major injury | 0.71% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 141 |
| Discharge self-care score | 62.86% |
53.69%
9.2 pts better
|
Numerator 66 · Denominator 105 |
| Discharge mobility score | 60.95% |
50.94%
10 pts better
|
Numerator 64 · Denominator 105 |
| Pressure ulcers or injuries, new or worsened | 2.86% |
2.29%
0.6 pts worse
|
Numerator 4 · Denominator 140 · Adjusted rate 4.63% |
| Healthcare-associated infections requiring hospitalization | 6.03% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 175 · Observed rate 4.57% · Lower 95% interval 3.88% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 60 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 162 |
| Discharge function score | 72.38% |
56.45%
15.9 pts better
|
Numerator 76 · Denominator 105 |
| Transfer of health information to provider | 84.48% |
95.95%
11.5 pts worse
|
Numerator 49 · Denominator 58 |
| Transfer of health information to patient | 95.45% |
96.28%
0.8 pts worse
|
Numerator 63 · Denominator 66 |
| Resident COVID-19 vaccinations up to date | 71.88% |
25.2%
46.7 pts better
|
Numerator 46 · Denominator 64 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.1% |
97.3%
6.2 pts worse
|
93.4%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 91.7% · Q2 83.3% · Q3 87.5% · Q4 100.0% · 4Q avg 91.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 85.2% |
96.1%
10.9 pts worse
|
95.5%
10.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 85.2% |
| 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 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.4% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.6% |
4.3%
1.7 pts better
|
11.4%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q4 4.0% · 4Q avg 2.6% |
| 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 4.8% · Q4 8.3% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.2% |
12.4%
5.2 pts better
|
19.6%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 9.5% · Q3 4.8% · Q4 8.3% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.1% |
17.5%
6.4 pts better
|
16.7%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.1% · 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 | 30.0% |
22.5%
7.5 pts worse
|
16.3%
13.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.0% |
18.6%
6.4 pts worse
|
14.9%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 13.4% |
2.3%
11.1 pts worse
|
1.0%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 10.7% · Q4 15.6% · 4Q avg 13.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.1% |
2.6%
0.5 pts worse
|
1.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 0.0% · Q3 0.0% · Q4 3.4% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.7% |
24.8%
6.9 pts worse
|
19.8%
11.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 23.7% · 4Q avg 31.7% |
| Percentage of long-stay residents with pressure ulcers | 9.1% |
5.4%
3.7 pts worse
|
5.1%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 18.7% · Q3 5.1% · Q4 7.5% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.6% |
88.6%
5 pts worse
|
81.7%
1.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.9% · Q2 83.0% · Q3 79.0% · Q4 81.4% · 4Q avg 83.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.2% |
14.0%
4.2 pts worse
|
12.0%
6.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.2% · Observed 16.5% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.9%
0.1 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.2% · Q3 1.3% · Q4 4.5% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.8% |
82.7%
2.9 pts worse
|
79.7%
0.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.7% |
23.1%
8.6 pts worse
|
23.9%
7.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.7% · Observed 30.4% · Expected 22.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-06 · Fire 2024-03-06
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-05-04 · Fire 2023-05-04
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-22
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-05-29
F · Potential for more than minimal harm
2025-04-22
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-05-29
F · Potential for more than minimal harm
2025-04-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-29
F · Potential for more than minimal harm
2025-04-22
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2025-05-29
D · Potential for more than minimal harm
2025-04-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-29
F · Potential for more than minimal harm
2024-03-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-10
F · Potential for more than minimal harm
2024-03-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-26
E · Potential for more than minimal harm
2024-03-06
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-04-10
E · Potential for more than minimal harm
2024-03-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-03-06
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-03-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-10
F · Potential for more than minimal harm
2023-05-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-31
F · Potential for more than minimal harm
2023-05-04
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2023-05-31
E · Potential for more than minimal harm
2023-05-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-05-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-31
C · Minimal harm
2023-05-04
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-05-31
C · Minimal harm
2023-05-04
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-05-31
C · Minimal harm
2023-05-04
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-05-31
Inspection history
Recent health citations
J · Immediate jeopardy
2025-08-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-09-18
F · Potential for more than minimal harm
2025-08-22
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-09-18
D · Potential for more than minimal harm
2025-08-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-18
G · Actual harm
2025-06-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-27
F · Potential for more than minimal harm
2025-06-27
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-08-27
J · Immediate jeopardy
2025-04-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-11
E · Potential for more than minimal harm
2025-04-22
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-05-29
E · Potential for more than minimal harm
2025-04-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-29
E · Potential for more than minimal harm
2025-04-22
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-05-29
D · Potential for more than minimal harm
2025-04-22
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-05-29
D · Potential for more than minimal harm
2025-04-22
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-05-29
D · Potential for more than minimal harm
2025-04-22
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 2025-05-29
D · Potential for more than minimal harm
2025-04-22
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 2025-05-29
D · Potential for more than minimal harm
2025-04-22
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-05-29
D · Potential for more than minimal harm
2025-04-22
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-05-29
D · Potential for more than minimal harm
2025-04-22
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-07-11
D · Potential for more than minimal harm
2025-04-22
F775 · Administration Deficiencies
Health
Keep complete, dated laboratory records in the resident's record.
Corrected 2025-05-29
D · Potential for more than minimal harm
2024-10-29
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 2024-11-26
D · Potential for more than minimal harm
2024-10-10
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-10-10
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-11-04
G · Actual harm
2024-09-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-09-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-25
D · Potential for more than minimal harm
2024-07-03
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-06-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-03-06
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 2024-04-10
D · Potential for more than minimal harm
2024-03-06
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 2024-04-10
F · Potential for more than minimal harm
2023-05-04
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-05-04
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 2023-05-31
D · Potential for more than minimal harm
2023-05-04
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 2023-05-31
D · Potential for more than minimal harm
2023-05-04
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-05-04
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-05-31
F · Potential for more than minimal harm
2023-04-04
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-05-12
E · Potential for more than minimal harm
2023-04-04
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 2023-05-12
D · Potential for more than minimal harm
2023-03-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-07
Penalties and ownership
What sits behind the stars
$0
2024-09-09
Payment Denial
Payment Denial · denial start 2024-09-28 · 6 days
6 day denial
Ownership
Volunteers Of America Care Facilities
5% Or Greater Direct Ownership Interest · Organization
Volunteers Of America National Services
5% Or Greater Indirect Ownership Interest · Organization
Anderson, Michael
Operational/Managerial Control · Individual
Arnold, Patti
Corporate Director · Individual
Bloom, Shawn
Corporate Director · Individual
Budzynski, Joseph
Corporate Officer · Individual
Chandra, Anupam
Operational/Managerial Control · Individual
Erickson, Karen
Corporate Director · Individual
Gavin, Nancy
Corporate Officer · Individual
Hackett, Karen
Corporate Director · Individual
King, Michael
Corporate Director · Individual
King, Michael
Corporate Officer · Individual
Knapp, Keith
Corporate Director · Individual
Mullen, Beth
Corporate Director · Individual
Nutz, Faith
Corporate Officer · Individual
Perkins, Derrick
Corporate Director · Individual
Peterson, Jeanne
Corporate Director · Individual
Rase, Nancy
Corporate Director · Individual
Robinson, Ann
Operational/Managerial Control · Individual
Sheridan, Patrick
Corporate Director · Individual
Soczynski, Paul
Operational/Managerial Control · Individual
Soczynski, Paul
Corporate Officer · Individual
Vigee, Voris
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Madonna Towers Of Rochester Inc
Rochester, MN
3-star overall rating with 3-star inspections with $10,196 in total fines with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Edenbrook Rochester West
Rochester, MN
2-star overall rating with 1-star inspections with $14,518 in total fines with 12 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#3
Edenbrook Of Rochester
Rochester, MN
2-star overall rating with 2-star inspections with $56,756 in total fines with 11 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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