Cycle 1
Health 2024-12-12 · Fire 2024-12-12
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Rochester, MN
Samaritan Bethany Home On Eighth
4-star overall rating with 4-star inspections with $42,502 in total fines with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
24 8th Street Northwest, Rochester, MN
(507) 289-4031
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
128
Certified beds
Average residents
91
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1988-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.59
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.72
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.63
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
3.94
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.39
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.67
CMS adjusted RN staffing hours
Adjusted total hours
4.52
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,639
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.14
Composite VBP score used to determine payment impact.
Payment multiplier
0.9921
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.02% · Performance 21.58% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.30
Baseline 5.00% · Performance 6.85% · Measure score 3.30 · Achievement 3.30 · Improvement 0
Total nurse turnover
6.32
Baseline 47.90% · Performance 37.86% · Measure score 6.32 · Achievement 6.32 · Improvement 3.85
Adjusted total nurse staffing
6.03
Baseline 5.45 hours · Performance 4.79 hours · Measure score 6.03 · Achievement 6.03 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.18% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 131 · Observed rate 6.11% · Lower 95% interval 6.23% |
| Discharge to community | 59.02% |
50.57%
8.5 pts better
|
No Different than the National Rate · Eligible stays 140 · Observed rate 55% · Lower 95% interval 49.63% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 101 · Denominator 101 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 101 |
| Discharge self-care score | 54.55% |
53.69%
0.9 pts better
|
Numerator 54 · Denominator 99 |
| Discharge mobility score | 27.27% |
50.94%
23.7 pts worse
|
Numerator 27 · Denominator 99 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 101 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.85% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 107 · Observed rate 5.61% · Lower 95% interval 3.59% |
| Staff COVID-19 vaccination coverage | 21.31% |
8.2%
13.1 pts better
|
Numerator 39 · Denominator 183 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 59.6% |
56.45%
3.1 pts better
|
Numerator 59 · Denominator 99 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 78 · Denominator 78 |
| Resident COVID-19 vaccinations up to date | 34.92% |
25.2%
9.7 pts better
|
Numerator 22 · Denominator 63 |
Quality measures
Resident outcomes and process scores
| 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 2.1 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
2.0
0.4 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
97.3%
0.5 pts worse
|
93.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 98.5% · Q3 95.7% · Q4 94.4% · 4Q avg 96.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.9% |
96.1%
1.2 pts worse
|
95.5%
0.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
3.9%
2.1 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 3.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.6% |
4.3%
2.7 pts better
|
11.4%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.5% · Q3 1.6% · Q4 1.5% · 4Q avg 1.6% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
4.1%
1.1 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 1.8% · Q3 5.5% · Q4 1.7% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.1% |
12.4%
7.3 pts better
|
19.6%
14.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 5.4% · Q3 5.2% · Q4 6.6% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.0% |
17.5%
13.5 pts better
|
16.7%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.1% · Q3 4.5% · Q4 4.3% · 4Q avg 4.0% · 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 | 24.3% |
22.5%
1.8 pts worse
|
16.3%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.8% |
18.6%
0.2 pts worse
|
14.9%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 15.7% · Q3 21.6% · Q4 17.0% · 4Q avg 18.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.6% |
2.3%
4.3 pts worse
|
1.0%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 3.1% · Q3 6.8% · Q4 10.9% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
2.6%
1.5 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.5% · Q3 0.0% · Q4 1.4% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.8% |
24.8%
4 pts worse
|
19.8%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.6% · Q2 24.4% · Q3 22.0% · Q4 37.8% · 4Q avg 28.8% |
| Percentage of long-stay residents with pressure ulcers | 9.8% |
5.4%
4.4 pts worse
|
5.1%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 3.5% · Q3 11.6% · Q4 12.0% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.0% |
88.6%
0.6 pts worse
|
81.7%
6.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.4% · Q2 89.7% · Q3 86.7% · Q4 86.2% · 4Q avg 88.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.1% |
14.0%
0.9 pts better
|
12.0%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.1% · Observed 11.6% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.9%
1.6 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 70.6% |
82.7%
12.1 pts worse
|
79.7%
9.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 70.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.4% |
23.1%
0.7 pts better
|
23.9%
1.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.4% · Observed 19.8% · Expected 21.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-01 · Fire 2024-02-01
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-10-28 · Fire 2022-10-28
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-01-24
D · Potential for more than minimal harm
2024-12-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-24
F · Potential for more than minimal harm
2024-02-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-08
F · Potential for more than minimal harm
2024-02-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-08
F · Potential for more than minimal harm
2024-02-01
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-03-08
F · Potential for more than minimal harm
2024-02-01
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-01
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-08
F · Potential for more than minimal harm
2022-10-28
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-12-09
F · Potential for more than minimal harm
2022-10-28
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 2022-12-09
F · Potential for more than minimal harm
2022-10-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-09
E · Potential for more than minimal harm
2022-10-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-09
E · Potential for more than minimal harm
2022-10-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-09
E · Potential for more than minimal harm
2022-10-28
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-12-09
E · Potential for more than minimal harm
2022-10-28
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2022-12-09
E · Potential for more than minimal harm
2022-10-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-12-09
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-12-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-01-24
G · Actual harm
2024-03-14
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 2024-04-12
D · Potential for more than minimal harm
2024-03-14
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 2024-04-12
E · Potential for more than minimal harm
2024-02-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-01
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-01
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 2024-03-08
D · Potential for more than minimal harm
2024-02-01
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-01
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 2024-03-08
D · Potential for more than minimal harm
2024-02-01
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-03-08
C · Minimal harm
2024-02-01
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2024-03-08
J · Immediate jeopardy
2023-05-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-05-11
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 2023-06-16
D · Potential for more than minimal harm
2023-05-11
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 2023-06-16
D · Potential for more than minimal harm
2022-10-28
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 2022-12-09
D · Potential for more than minimal harm
2022-10-28
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-12-09
Penalties and ownership
What sits behind the stars
$27,555
2024-03-14
Fine
Fine · fine $27,555
Fine
$0
2024-03-14
Payment Denial
Payment Denial · denial start 2024-04-09 · 3 days
3 day denial
$14,947
2023-05-11
Fine
Fine · fine $14,947
Fine
Ownership
Bakken, Kirby
Corporate Director · Individual
Bakken, Kirby
Corporate Officer · Individual
Beaulieu, Robert
Corporate Director · Individual
Beaulieu, Robert
Corporate Officer · Individual
Berg, Kyla
W-2 Managing Employee · Individual
Bird, Terry
Corporate Director · Individual
Bird, Terry
Corporate Officer · Individual
Davis, Scott
Corporate Director · Individual
Davis, Scott
Corporate Officer · Individual
Deyoung, Laurie
Corporate Director · Individual
Deyoung, Laurie
Corporate Officer · Individual
Dunn, Rachel
Corporate Director · Individual
Dunn, Rachel
Corporate Officer · Individual
Faudi, Jerad
Corporate Director · Individual
Faudi, Jerad
Corporate Officer · Individual
Hartman, Karen
Corporate Director · Individual
Hartman, Karen
Corporate Officer · Individual
Haug, John
Corporate Director · Individual
Haug, John
Corporate Officer · Individual
Knutson, Susan
Corporate Officer · Individual
Knutson, Susan
W-2 Managing Employee · Individual
Miller, Brandon
Corporate Officer · Individual
Miller, Brandon
W-2 Managing Employee · Individual
Moravec, Beverly
Corporate Director · Individual
Moravec, Beverly
Corporate Officer · Individual
Phillips, Joseph
Corporate Director · Individual
Phillips, Joseph
Corporate Officer · Individual
Shulze, Pamela
Corporate Director · Individual
Shulze, Pamela
Corporate Officer · Individual
Swanson, Jerry
Corporate Director · Individual
Swanson, Jerry
Corporate Officer · Individual
Zander, Gary
Corporate Director · Individual
Zander, Gary
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Charter House Inc
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5-star overall rating with 5-star inspections with $8,824 in total fines with 3 fire-safety deficiencies in the latest cycle
#2
Rochester Restorative Care Center
Rochester, MN
2-star overall rating with 1-star inspections with $111,761 in total fines with 24 recent health deficiencies with 18 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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