Cycle 1
Health 2025-07-23 · Fire 2025-07-23
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Shakopee, MN
Shakopee Friendship Manor
3-star overall rating with 4-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1340 Third Avenue West, Shakopee, MN
(952) 445-4155
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
50
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1987-03-01
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
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
96
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
86.25
Composite VBP score used to determine payment impact.
Payment multiplier
1.0269
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
10
Baseline 15.69% · Performance 24.00% · Measure score 10 · Achievement 10 · Improvement 0
Adjusted total nurse staffing
7.25
Baseline 4.64 hours · Performance 5.14 hours · Measure score 7.25 · Achievement 7.25 · Improvement 3.87
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 16 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 6.54% |
8.2%
1.7 pts worse
|
Numerator 7 · Denominator 107 |
| Staff flu vaccination coverage | 31.43% |
42%
10.6 pts worse
|
Numerator 33 · Denominator 105 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.3%
2.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 6.5% |
3.9%
2.6 pts worse
|
3.3%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 6.4% · Q3 6.5% · Q4 8.5% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.3%
4.3 pts better
|
11.4%
11.4 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 who lose too much weight | 3.6% |
4.1%
0.5 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.5% · Q3 4.9% · Q4 0.0% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.9% |
12.4%
3.5 pts better
|
19.6%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 9.5% · Q3 9.8% · Q4 9.5% · 4Q avg 8.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.5% |
17.5%
3 pts better
|
16.7%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 14.3% · Q3 14.7% · Q4 16.7% · 4Q avg 14.5% · 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 | 26.9% |
22.5%
4.4 pts worse
|
16.3%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 37.3% · 4Q avg 26.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.5% |
18.6%
4.9 pts worse
|
14.9%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 29.6% · Q3 14.3% · Q4 30.3% · 4Q avg 23.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.3%
2.3 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
2.6%
0.4 pts better
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 2.1% · Q3 0.0% · Q4 2.1% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.0% |
24.8%
4.2 pts worse
|
19.8%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 28.7% · Q3 25.8% · Q4 36.8% · 4Q avg 29.0% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
5.4%
2.2 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 3.9% · Q3 4.1% · Q4 0.0% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.5% |
88.6%
0.1 pts worse
|
81.7%
6.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 87.9% · Q2 80.6% · Q3 90.2% · Q4 94.7% · 4Q avg 88.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.4% |
14.0%
8.6 pts better
|
12.0%
6.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.4% · Observed 5.0% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 6.3% |
1.9%
4.4 pts worse
|
1.6%
4.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 8.0% · Q3 3.4% · Q4 9.5% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 64.9% |
82.7%
17.8 pts worse
|
79.7%
14.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 64.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.1% |
23.1%
3 pts worse
|
23.9%
2.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.1% · Observed 20.0% · Expected 18.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-05 · Fire 2024-06-05
3 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-05-18 · Fire 2023-05-18
6 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-07-28
D · Potential for more than minimal harm
2025-07-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-23
C · Minimal harm
2025-07-23
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-08-22
F · Potential for more than minimal harm
2024-06-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-06-17
F · Potential for more than minimal harm
2024-06-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-31
E · Potential for more than minimal harm
2024-06-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-06
E · Potential for more than minimal harm
2024-06-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-06
F · Potential for more than minimal harm
2023-05-18
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-07-06
F · Potential for more than minimal harm
2023-05-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-17
E · Potential for more than minimal harm
2023-05-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-05-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-18
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-05-19
C · Minimal harm
2023-05-18
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-06-15
C · Minimal harm
2023-05-18
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-07-17
C · Minimal harm
2023-05-18
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-07-06
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-07-23
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-07-23
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 2025-08-22
D · Potential for more than minimal harm
2025-07-23
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-07-23
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-08-22
D · Potential for more than minimal harm
2024-06-05
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 2024-07-15
D · Potential for more than minimal harm
2024-06-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-15
C · Minimal harm
2024-06-05
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-07-15
D · Potential for more than minimal harm
2023-05-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-18
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-18
F756 · Pharmacy Service Deficiencies
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 2023-07-17
D · Potential for more than minimal harm
2023-05-18
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 2023-07-17
D · Potential for more than minimal harm
2023-05-18
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-07-06
Penalties and ownership
What sits behind the stars
Ownership
Probst, Seth
5% Or Greater Direct Ownership Interest · Individual
Fairbairn, Scott
Operational/Managerial Control · Individual
Mohlin, Jamie
Operational/Managerial Control · Individual
Probst, Seth
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
St Gertrudes Health & Rehabilitation Center
Shakopee, MN
3-star overall rating with 2-star inspections with $29,260 in total fines with 13 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Auburn Manor
Chaska, MN
1-star overall rating with 1-star inspections with 15 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Flagstone
Eden Prairie, MN
4-star overall rating with 3-star inspections with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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