West Saint Paul, MN

Southview Acres HealthCare Center

3-star overall rating with 2-star inspections with $41,555 in total fines with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

2000 Oakdale Avenue, West Saint Paul, MN

(651) 554-9558

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 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

210

Certified beds

Average residents

171

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Akiko Ike

Operator or chain grouping

Approved since

1974-04-15

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

7 facilities

Chain averages 4 overall / 3 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

0.90

Registered nurse staffing · state 1.06 · national 0.68

LPN hours / resident day

0.94

Licensed practical nurse staffing · state 0.62 · national 0.87

Aide hours / resident day

2.42

Nurse aide staffing · state 2.56 · national 2.35

Total nurse hours

4.26

All reported nurse hours · state 4.23 · national 3.89

Licensed hours

1.84

RN + LPN hours · state 1.68 · national 1.54

Weekend hours

3.79

Weekend nurse staffing · state 3.68 · national 3.43

Weekend RN hours

0.51

Weekend registered nurse coverage · state 0.68 · national 0.47

Physical therapist

0.08

Reported PT staffing · state 0.08 · national 0.07

Adjusted RN hours

1.01

CMS adjusted RN staffing hours

Adjusted total hours

4.75

CMS adjusted total nurse staffing hours

Case-mix index

1.23

Higher values indicate more complex resident acuity

RN turnover

41%

Annual RN turnover · state 39% · national 45%

Total nurse turnover

42%

Annual nurse turnover · state 42% · national 46%

SNF VBP

Value-based purchasing

Program rank

6,909

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

31.36

Composite VBP score used to determine payment impact.

Payment multiplier

0.9865

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.07

Baseline 18.16% · Performance 20.01% · Measure score 3.07 · Achievement 3.07 · Improvement 0

Healthcare-associated infections

2.41

Baseline 7.98% · Performance 7.11% · Measure score 2.41 · Achievement 2.41 · Improvement 2.41

Total nurse turnover

3.35

Baseline 39.68% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 0

Adjusted total nurse staffing

3.71

Baseline 3.30 hours · Performance 4.13 hours · Measure score 3.71 · Achievement 3.71 · Improvement 2.85

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 11.59%
10.72%
0.9 pts worse
No Different than the National Rate · Eligible stays 127 · Observed rate 13.39% · Lower 95% interval 8.04%
Discharge to community 43.58%
50.57%
7 pts worse
No Different than the National Rate · Eligible stays 120 · Observed rate 36.67% · Lower 95% interval 36.91%
Medicare spending per beneficiary 0.79
1.02
0.2 pts better
Drug regimen review with follow-up 85.71%
95.27%
9.6 pts worse
Numerator 66 · Denominator 77
Falls with major injury 3.9%
0.77%
3.1 pts worse
Numerator 3 · Denominator 77
Discharge self-care score 65%
53.69%
11.3 pts better
Numerator 39 · Denominator 60
Discharge mobility score 46.67%
50.94%
4.3 pts worse
Numerator 28 · Denominator 60
Pressure ulcers or injuries, new or worsened 1.32%
2.29%
1 pts better
Numerator 1 · Denominator 76 · Adjusted rate 1.14%
Healthcare-associated infections requiring hospitalization 7.11%
7.12%
About the same
No Different than the National Rate · Eligible stays 64 · Observed rate 7.81% · Lower 95% interval 3.58%
Staff COVID-19 vaccination coverage 0%
8.2%
8.2 pts worse
Numerator 0 · Denominator 253
Staff flu vaccination coverage 54.87%
42%
12.9 pts better
Numerator 152 · Denominator 277
Discharge function score 71.67%
56.45%
15.2 pts better
Numerator 43 · Denominator 60
Transfer of health information to provider Not Available
95.95%
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.
Transfer of health information to patient 97.3%
96.28%
1 pts better
Numerator 36 · Denominator 37
Resident COVID-19 vaccinations up to date 23.53%
25.2%
1.7 pts worse
Numerator 8 · Denominator 34

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 1.4
1.7
0.3 pts better
1.9
0.5 pts better
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.2 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 1.0
2.0
1 pts better
1.8
0.8 pts better
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.5 · 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 97.9% · Q2 96.5% · Q3 98.6% · Q4 93.9% · 4Q avg 96.8%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 98.1%
96.1%
2 pts better
95.5%
2.6 pts better
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1%
Percentage of long-stay residents experiencing one or more falls with major injury 3.4%
3.9%
0.5 pts better
3.3%
0.1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.8% · Q3 3.5% · Q4 4.6% · 4Q avg 3.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 5.1%
4.3%
0.8 pts worse
11.4%
6.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 4.0% · Q3 5.6% · Q4 6.0% · 4Q avg 5.1%
Percentage of long-stay residents who lose too much weight 5.0%
4.1%
0.9 pts worse
5.4%
0.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 6.8% · Q3 2.7% · Q4 4.6% · 4Q avg 5.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 6.5%
12.4%
5.9 pts better
19.6%
13.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 9.4% · Q3 4.4% · Q4 5.5% · 4Q avg 6.5%
Percentage of long-stay residents who received an antipsychotic medication 18.0%
17.5%
0.5 pts worse
16.7%
1.3 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 24.7% · Q3 10.5% · Q4 11.4% · 4Q avg 18.0% · 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 26.5%
22.5%
4 pts worse
16.3%
10.2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 42.5% · Q2 29.4% · Q3 27.7% · Q4 10.0% · 4Q avg 26.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 22.7%
18.6%
4.1 pts worse
14.9%
7.8 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 38.8% · Q2 15.0% · Q3 21.2% · Q4 15.1% · 4Q avg 22.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 1.2%
2.3%
1.1 pts better
1.0%
0.2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.1% · Q3 1.2% · Q4 0.6% · 4Q avg 1.2% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 3.0%
2.6%
0.4 pts worse
1.7%
1.3 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.8% · Q3 6.3% · Q4 1.5% · 4Q avg 3.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 30.6%
24.8%
5.8 pts worse
19.8%
10.8 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 36.7% · Q2 25.9% · Q3 29.3% · Q4 30.4% · 4Q avg 30.6%
Percentage of long-stay residents with pressure ulcers 7.6%
5.4%
2.2 pts worse
5.1%
2.5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 10.3% · Q3 5.5% · Q4 5.2% · 4Q avg 7.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 77.6%
88.6%
11 pts worse
81.7%
4.1 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 84.7% · Q2 85.3% · Q3 75.1% · Q4 69.1% · 4Q avg 77.6%
Percentage of short-stay residents who had an outpatient emergency department visit 5.7%
14.0%
8.3 pts better
12.0%
6.3 pts better
Short Stay · 20240701-20250630 · Adjusted 5.7% · Observed 6.0% · Expected 11.7% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 2.5%
1.9%
0.6 pts worse
1.6%
0.9 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 1.7% · Q3 2.5% · Q4 2.9% · 4Q avg 2.5% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 78.4%
82.7%
4.3 pts worse
79.7%
1.3 pts worse
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.4%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 17.0%
23.1%
6.1 pts better
23.9%
6.9 pts better
Short Stay · 20240701-20250630 · Adjusted 17.0% · Observed 16.4% · Expected 23.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-09 · Fire 2025-01-09

14 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

1 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Cycle 2 Health 2023-11-30 · Fire 2023-11-30

8 health deficiencies

Top issue: Infection Control (2 deficiencies)

6 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Cycle 3 Health 2022-09-29 · Fire 2022-09-29

21 health deficiencies

Top issue: Quality of Life and Care (10 deficiencies)

9 fire-safety deficiencies

Top issue: Egress (3 deficiencies)

Fire safety

Fire-safety citations

C · Minimal harm 2025-01-09

E25 · Emergency Preparedness Deficiencies

Fire Safety

Create arrangements with other facilities to receive patients.

Corrected 2025-01-28

F · Potential for more than minimal harm 2023-11-30

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-01-31

E · Potential for more than minimal harm 2023-11-30

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Not marked corrected

E · Potential for more than minimal harm 2023-11-30

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Not marked corrected

E · Potential for more than minimal harm 2023-11-30

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Not marked corrected

E · Potential for more than minimal harm 2023-11-30

K753 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of highly flammable decorations.

Corrected 2023-12-25

E · Potential for more than minimal harm 2023-11-30

K927 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Corrected 2023-12-25

F · Potential for more than minimal harm 2022-09-29

K131 · Construction Deficiencies

Fire Safety

Meet requirements for sections of health care facilities separated by fire resistive construction.

Corrected 2022-11-07

F · Potential for more than minimal harm 2022-09-29

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2022-11-07

E · Potential for more than minimal harm 2022-09-29

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2022-11-07

E · Potential for more than minimal harm 2022-09-29

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Not marked corrected

E · Potential for more than minimal harm 2022-09-29

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2022-11-07

E · Potential for more than minimal harm 2022-09-29

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-11-07

D · Potential for more than minimal harm 2022-09-29

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2022-11-07

D · Potential for more than minimal harm 2022-09-29

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2022-11-07

D · Potential for more than minimal harm 2022-09-29

K930 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper storage of liquid oxygen.

Corrected 2022-11-07

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-06-26

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-03-27

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-04-22

E · Potential for more than minimal harm 2025-01-09

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2025-01-28

D · Potential for more than minimal harm 2025-01-09

F553 · Resident Rights Deficiencies

Health

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Corrected 2025-01-28

D · Potential for more than minimal harm 2025-01-09

F638 · Resident Assessment and Care Planning Deficiencies

Health

Assure that each resident’s assessment is updated at least once every 3 months.

Corrected 2025-01-28

D · Potential for more than minimal harm 2025-01-09

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 2025-01-28

D · Potential for more than minimal harm 2025-01-09

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 2025-01-28

D · Potential for more than minimal harm 2025-01-09

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2025-01-28

D · Potential for more than minimal harm 2025-01-09

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-01-28

D · Potential for more than minimal harm 2025-01-09

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 2025-01-28

D · Potential for more than minimal harm 2025-01-09

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2025-01-28

D · Potential for more than minimal harm 2025-01-09

F773 · Administration Deficiencies

Health

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

Corrected 2025-01-28

D · Potential for more than minimal harm 2025-01-09

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 2025-01-28

D · Potential for more than minimal harm 2025-01-09

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-01-28

G · Actual harm 2024-02-07

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 2024-02-09

D · Potential for more than minimal harm 2024-01-30

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 2024-02-09

D · Potential for more than minimal harm 2024-01-30

F553 · Resident Rights Deficiencies

Health

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Corrected 2024-02-09

G · Actual harm 2024-01-12

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 2024-02-09

D · Potential for more than minimal harm 2024-01-12

F572 · Resident Rights Deficiencies

Health

Give residents a notice of rights, rules, services and charges.

Corrected 2024-02-09

D · Potential for more than minimal harm 2024-01-12

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-02-09

D · Potential for more than minimal harm 2024-01-12

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 2024-02-09

D · Potential for more than minimal harm 2024-01-12

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-02-09

D · Potential for more than minimal harm 2024-01-12

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-02-09

E · Potential for more than minimal harm 2023-11-30

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-12-27

D · Potential for more than minimal harm 2023-11-30

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 2023-12-27

D · Potential for more than minimal harm 2023-11-30

F637 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident when there is a significant change in condition

Corrected 2023-12-27

D · Potential for more than minimal harm 2023-11-30

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 2023-12-27

D · Potential for more than minimal harm 2023-11-30

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 2023-12-27

D · Potential for more than minimal harm 2023-11-30

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 2023-12-27

D · Potential for more than minimal harm 2023-11-30

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 2023-12-27

D · Potential for more than minimal harm 2023-11-30

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2023-12-27

D · Potential for more than minimal harm 2023-09-28

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-10-18

D · Potential for more than minimal harm 2023-05-03

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 2023-05-26

D · Potential for more than minimal harm 2023-03-02

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 2023-03-21

E · Potential for more than minimal harm 2022-09-29

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 2022-11-08

D · Potential for more than minimal harm 2022-09-29

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2022-11-08

D · Potential for more than minimal harm 2022-09-29

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2022-11-08

D · Potential for more than minimal harm 2022-09-29

F676 · Quality of Life and Care Deficiencies

Health

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected 2022-11-08

D · Potential for more than minimal harm 2022-09-29

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 2022-11-08

D · Potential for more than minimal harm 2022-09-29

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2022-11-08

D · Potential for more than minimal harm 2022-09-29

F745 · Quality of Life and Care Deficiencies

Health

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Corrected 2022-11-08

D · Potential for more than minimal harm 2022-09-29

F811 · Nutrition and Dietary Deficiencies

Health

Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.

Corrected 2022-11-08

D · Potential for more than minimal harm 2022-09-29

F948 · Nursing and Physician Services Deficiencies

Health

Ensure that paid feeding assistants have the training they need.

Corrected 2022-11-08

Penalties and ownership

What sits behind the stars

$41,555 2023-11-30

Fine

Fine · fine $41,555

Fine

Ownership

Bogey Holdings, LLC

5% Or Greater Direct Ownership Interest · Organization

100% 1 facilities 2019-02-25
Ike, Akiko

5% Or Greater Indirect Ownership Interest · Individual

100% 9 facilities 2019-02-25
Cook, Jeffrey

W-2 Managing Employee · Individual

0% 1 facilities 2019-02-25

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