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
Chain footprint
4 facilities
Chain averages 5 overall / 4 health / 5 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
0.27
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.56
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.73
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
2.17
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.33
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
1.50
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
2.07
CMS adjusted RN staffing hours
Adjusted total hours
5.13
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
23%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
23%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
656
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
65.85
Composite VBP score used to determine payment impact.
Payment multiplier
1.0199
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2
Baseline 18.20% · Performance 20.51% · Measure score 2 · Achievement 2 · Improvement 0
Healthcare-associated infections
8.85
Baseline 4.83% · Performance 5.19% · Measure score 8.85 · Achievement 8.85 · Improvement 0
Total nurse turnover
9.31
Baseline 46.59% · Performance 25.61% · Measure score 9.31 · Achievement 9.31 · Improvement 9
Adjusted total nurse staffing
6.18
Baseline 4.69 hours · Performance 4.84 hours · Measure score 6.18 · Achievement 6.18 · Improvement 0.82
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.3% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 257 · Observed rate 8.17% · Lower 95% interval 7.67% |
| Discharge to community | 69.95% |
50.57%
19.4 pts better
|
Better than the National Rate · Eligible stays 259 · Observed rate 70.66% · Lower 95% interval 64.44% |
| Medicare spending per beneficiary | 0.7 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 99.14% |
95.27%
3.9 pts better
|
Numerator 115 · Denominator 116 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 116 |
| Discharge self-care score | 63.64% |
53.69%
10 pts better
|
Numerator 63 · Denominator 99 |
| Discharge mobility score | 58.59% |
50.94%
7.7 pts better
|
Numerator 58 · Denominator 99 |
| Pressure ulcers or injuries, new or worsened | 0.86% |
2.29%
1.4 pts better
|
Numerator 1 · Denominator 116 · Adjusted rate 1.14% |
| Healthcare-associated infections requiring hospitalization | 5.19% |
7.12%
1.9 pts better
|
No Different than the National Rate · Eligible stays 159 · Observed rate 1.89% · Lower 95% interval 3.07% |
| Staff COVID-19 vaccination coverage | 10.88% |
8.2%
2.7 pts better
|
Numerator 21 · Denominator 193 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 70.71% |
56.45%
14.3 pts better
|
Numerator 70 · Denominator 99 |
| Transfer of health information to provider | 95.06% |
95.95%
0.9 pts worse
|
Numerator 77 · Denominator 81 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 20 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 53.33% |
25.2%
28.1 pts better
|
Numerator 32 · Denominator 60 |
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 · Adjusted 2.1 · Observed 1.8 · Expected 1.6 · Used in QM five-star |
| 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 · Adjusted 0.6 · Observed 0.5 · Expected 1.4 · Used in QM five-star |
| 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 · Q1 89.2% · Q2 100.0% · Q3 100.0% · Q4 97.3% · 4Q avg 96.7% |
| 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 · 4Q avg 97.6% |
| 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 · Q1 2.7% · Q2 0.0% · Q3 5.3% · Q4 8.1% · 4Q avg 4.0% · Used in QM five-star |
| 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 · Q1 19.2% · Q2 14.8% · Q3 3.7% · Q4 5.9% · 4Q avg 10.5% |
| 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 · Q1 0.0% · Q2 3.2% · Q3 0.0% · Q4 3.4% · 4Q avg 1.7% |
| 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 · Q1 12.5% · Q2 6.5% · Q3 3.7% · Q4 6.9% · 4Q avg 7.6% |
| 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 · Q1 16.7% · Q2 13.6% · Q3 9.1% · Q4 14.8% · 4Q avg 13.9% · 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 ability to walk independently worsened | 47.9% |
22.5%
25.4 pts worse
|
16.3%
31.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 47.9% · Used in QM five-star |
| 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 · Q1 27.3% · Q2 13.6% · Q4 19.2% · 4Q avg 19.5% · 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 2.8% · Q2 0.0% · Q3 0.0% · Q4 3.9% · 4Q avg 1.7% · Used in QM five-star |
| 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 · 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 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 · Q1 52.0% · Q2 34.7% · Q3 41.1% · Q4 28.2% · 4Q avg 39.2% |
| 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 · Q1 0.0% · Q2 2.2% · Q3 6.2% · Q4 5.7% · 4Q avg 3.5% · Used in QM five-star |
| 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 · Q1 88.1% · Q2 90.4% · Q3 96.0% · Q4 94.8% · 4Q avg 92.5% |
| 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 · Adjusted 7.0% · Observed 6.1% · Expected 9.7% · Used in QM five-star |
| 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 · Q1 1.5% · Q2 1.6% · Q3 0.7% · Q4 1.5% · 4Q avg 1.3% · Used in QM five-star |
| 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 · 4Q avg 95.9% |
| 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 · Adjusted 34.8% · Observed 26.5% · Expected 18.2% · Used in QM five-star |
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
Other facilities in reach
#1
Maranatha Care Center
Brooklyn Center, MN
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
The Villas At Osseo LLC
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
Jump out