Cycle 1
Health 2024-12-06 · Fire 2024-12-06
6 health deficiencies
Top issue: Resident Rights (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Brooklyn Park, MN
Saint Therese At Oxbow Lake
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
9751 Regent Avenue North, Brooklyn Park, MN
(763) 493-7007
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
64
Certified beds
Average residents
60
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Saint Therese Senior Communities
Operator or chain grouping
Approved since
2013-07-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.90
Registered nurse staffing
LPN hours / resident day
0.27
Licensed practical nurse staffing
Aide hours / resident day
2.56
Nurse aide staffing
Weekend hours
4.33
Weekend nurse staffing
RN turnover
23%
Annual RN turnover
Total nurse turnover
23%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.7
0.4 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
2.0
1.4 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
97.3%
0.6 pts worse
|
93.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.6% |
96.1%
1.5 pts better
|
95.5%
2.1 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
3.9%
0.1 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 10.5% |
4.3%
6.2 pts worse
|
11.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 1.7% |
4.1%
2.4 pts better
|
5.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.6% |
12.4%
4.8 pts better
|
19.6%
12 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 13.9% |
17.5%
3.6 pts better
|
16.7%
2.8 pts better
|
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 | 47.9% |
22.5%
25.4 pts worse
|
16.3%
31.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.5% |
18.6%
0.9 pts worse
|
14.9%
4.6 pts worse
|
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 | 0.0% |
2.6%
2.6 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 39.2% |
24.8%
14.4 pts worse
|
19.8%
19.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
5.4%
1.9 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.5% |
88.6%
3.9 pts better
|
81.7%
10.8 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.0% |
14.0%
7 pts better
|
12.0%
5 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.9%
0.6 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.9% |
82.7%
13.2 pts better
|
79.7%
16.2 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.8% |
23.1%
11.7 pts worse
|
23.9%
10.9 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-07 · Fire 2024-03-07
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-04-19 · Fire 2023-04-19
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-12-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-12-06
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-12-31
D · Potential for more than minimal harm
2024-12-06
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 2025-01-03
D · Potential for more than minimal harm
2024-12-06
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-12-31
F · Potential for more than minimal harm
2024-03-07
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-05-03
F · Potential for more than minimal harm
2024-03-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-12
F · Potential for more than minimal harm
2024-03-07
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-05-03
F · Potential for more than minimal harm
2024-03-07
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 2024-05-03
E · Potential for more than minimal harm
2024-03-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-03-07
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-03-27
F · Potential for more than minimal harm
2023-04-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-25
F · Potential for more than minimal harm
2023-04-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-04-19
K930 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper storage of liquid oxygen.
Corrected 2023-05-26
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-12-06
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 2025-01-27
F · Potential for more than minimal harm
2024-12-06
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 2025-01-27
D · Potential for more than minimal harm
2024-12-06
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-06
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-06
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-10-11
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-08-07
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-09-11
D · Potential for more than minimal harm
2024-08-07
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 2024-09-11
D · Potential for more than minimal harm
2024-03-07
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 2024-05-03
D · Potential for more than minimal harm
2024-03-07
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 2024-05-03
D · Potential for more than minimal harm
2024-03-07
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 2024-05-03
D · Potential for more than minimal harm
2024-03-07
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-03-07
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 2024-05-03
D · Potential for more than minimal harm
2023-04-19
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-05-26
C · Minimal harm
2023-04-19
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 2023-05-23
Penalties and ownership
What sits behind the stars
Ownership
Saint Therese
5% Or Greater Indirect Ownership Interest · Organization
Saint Therese Communities
5% Or Greater Direct Ownership Interest · Organization
Abbott, Craig
Corporate Director · Individual
Abbott, Craig
Corporate Officer · Individual
Bremer Bank National Association
5% Or Greater Mortgage Interest · Organization
Delander, Christine
Operational/Managerial Control · Individual
Gillespie, Joseph
Corporate Director · Individual
Herb, Mary
Corporate Director · Individual
Hoffmann, David
Corporate Director · Individual
Hoffmann, David
Corporate Officer · Individual
Horstmann, Steven
Corporate Director · Individual
Krenn, David
Corporate Director · Individual
Mccluskey, Patricia
Corporate Director · Individual
Mccrossan, Jane
Corporate Director · Individual
Meads, Steven
Corporate Director · Individual
Mittal, Vikas
Operational/Managerial Control · Individual
Parmar, Mona
Corporate Director · Individual
Peterson, Tessa
Operational/Managerial Control · Individual
Saint Therese
Operational/Managerial Control · Organization
Saint Therese Communities
Operational/Managerial Control · Organization
Saint Therese Management Services, LLC
Operational/Managerial Control · Organization
Shelangoski, Cal
Corporate Officer · Individual
Taffe, Patrick
Corporate Director · Individual
Wornson, Kathryn
Corporate Director · Individual
Wornson, Kathryn
Corporate Officer · Individual
Nearby options
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5-star overall rating with 4-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
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Osseo, MN
2-star overall rating with 2-star inspections with $47,775 in total fines with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Park River Estates Care Center
Coon Rapids, MN
4-star overall rating with 2-star inspections with 18 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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