Cycle 1
Health 2025-02-14 · Fire 2025-02-14
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Mora, MN
St Clare Living Community Of Mora
4-star overall rating with 3-star inspections with $45,100 in total fines with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
110 North 7th Street, Mora, MN
(320) 679-1411
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
65
Certified beds
Average residents
48
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1985-09-01
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
0.85
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.74
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.18
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
3.77
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.59
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.19
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.99
CMS adjusted RN staffing hours
Adjusted total hours
4.40
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
15%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,187
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.14
Composite VBP score used to determine payment impact.
Payment multiplier
1.0054
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.63
Baseline 19.91% · Performance 19.75% · Measure score 3.63 · Achievement 3.63 · Improvement 0.05
Healthcare-associated infections
3.53
Baseline 5.36% · Performance 6.78% · Measure score 3.53 · Achievement 3.53 · Improvement 0
Total nurse turnover
7.55
Baseline 26.00% · Performance 32.81% · Measure score 7.55 · Achievement 7.55 · Improvement 0
Adjusted total nurse staffing
5.75
Baseline 4.78 hours · Performance 4.71 hours · Measure score 5.75 · Achievement 5.75 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.07% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 76 · Observed rate 11.84% · Lower 95% interval 7.99% |
| Discharge to community | 65.73% |
50.57%
15.2 pts better
|
Better than the National Rate · Eligible stays 63 · Observed rate 71.43% · Lower 95% interval 54.51% |
| Medicare spending per beneficiary | 0.48 |
1.02
0.5 pts better
|
|
| Drug regimen review with follow-up | 90.12% |
95.27%
5.1 pts worse
|
Numerator 73 · Denominator 81 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 80 |
| Discharge self-care score | 61.97% |
53.69%
8.3 pts better
|
Numerator 44 · Denominator 71 |
| Discharge mobility score | 61.97% |
50.94%
11 pts better
|
Numerator 44 · Denominator 71 |
| Pressure ulcers or injuries, new or worsened | 1.25% |
2.29%
1 pts better
|
Numerator 1 · Denominator 80 · Adjusted rate 1.87% |
| Healthcare-associated infections requiring hospitalization | 6.78% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 43 · Observed rate 4.65% · Lower 95% interval 3.65% |
| Staff COVID-19 vaccination coverage | 19.01% |
8.2%
10.8 pts better
|
Numerator 23 · Denominator 121 |
| Staff flu vaccination coverage | 57.5% |
42%
15.5 pts better
|
Numerator 69 · Denominator 120 |
| Discharge function score | 78.87% |
56.45%
22.4 pts better
|
Numerator 56 · Denominator 71 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 91.38% |
96.28%
4.9 pts worse
|
Numerator 53 · Denominator 58 |
| Resident COVID-19 vaccinations up to date | 38.46% |
25.2%
13.3 pts better
|
Numerator 15 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
97.3%
1.5 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.6% · Q4 97.6% · 4Q avg 98.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.6% |
96.1%
0.5 pts worse
|
95.5%
0.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.6% |
3.9%
3.3 pts better
|
3.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · 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 | 3.1% |
4.1%
1 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 0.0% · Q3 3.1% · Q4 3.0% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.5% |
12.4%
2.1 pts worse
|
19.6%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 18.8% · Q3 15.2% · Q4 9.1% · 4Q avg 14.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.7% |
17.5%
9.2 pts worse
|
16.7%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 25.8% · Q3 30.0% · Q4 24.1% · 4Q avg 26.7% · 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 | 18.7% |
22.5%
3.8 pts better
|
16.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.0% |
18.6%
6.4 pts worse
|
14.9%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 34.6% · Q3 23.1% · Q4 25.9% · 4Q avg 25.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.9% |
2.3%
1.6 pts worse
|
1.0%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 4.2% · Q3 3.4% · Q4 4.9% · 4Q avg 3.9% · 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 4.7% · Q2 0.0% · Q3 2.4% · Q4 4.9% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.3% |
24.8%
0.5 pts worse
|
19.8%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 21.3% · Q3 36.7% · Q4 22.9% · 4Q avg 25.3% |
| Percentage of long-stay residents with pressure ulcers | 6.3% |
5.4%
0.9 pts worse
|
5.1%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 6.3% · Q3 4.8% · Q4 6.7% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
88.6%
9 pts better
|
81.7%
15.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 96.8% · Q3 96.1% · Q4 98.9% · 4Q avg 97.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.5% |
14.0%
3.5 pts worse
|
12.0%
5.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.5% · Observed 18.4% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.9% |
82.7%
8.2 pts better
|
79.7%
11.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.5% |
23.1%
1.6 pts better
|
23.9%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.5% · Observed 18.4% · Expected 20.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-28 · Fire 2023-12-28
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-03-16 · Fire 2023-03-16
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-18
F · Potential for more than minimal harm
2025-02-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-18
F · Potential for more than minimal harm
2025-02-14
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-02-18
F · Potential for more than minimal harm
2025-02-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-18
F · Potential for more than minimal harm
2023-12-28
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 2023-12-29
D · Potential for more than minimal harm
2023-12-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-26
D · Potential for more than minimal harm
2023-12-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-12-27
F · Potential for more than minimal harm
2023-03-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-16
F · Potential for more than minimal harm
2023-03-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-23
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-14
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 2025-04-03
E · Potential for more than minimal harm
2025-02-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-02-14
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-02-14
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-02-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-02-14
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-02-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-02-14
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 2025-04-03
D · Potential for more than minimal harm
2025-02-14
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-02-14
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-04-03
D · Potential for more than minimal harm
2024-04-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-13
D · Potential for more than minimal harm
2024-04-12
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 2024-05-13
E · Potential for more than minimal harm
2023-12-28
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-02-05
D · Potential for more than minimal harm
2023-12-28
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-02-05
D · Potential for more than minimal harm
2023-12-28
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-02-05
D · Potential for more than minimal harm
2023-12-28
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 2024-02-05
D · Potential for more than minimal harm
2023-12-28
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-02-05
D · Potential for more than minimal harm
2023-12-28
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-02-05
D · Potential for more than minimal harm
2023-12-28
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 2024-02-05
D · Potential for more than minimal harm
2023-12-28
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2024-02-05
C · Minimal harm
2023-12-28
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-02-05
D · Potential for more than minimal harm
2023-09-01
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 2023-10-02
G · Actual harm
2023-07-27
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 2023-09-01
D · Potential for more than minimal harm
2023-03-16
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 2023-05-08
D · Potential for more than minimal harm
2023-03-16
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 2023-05-08
D · Potential for more than minimal harm
2023-03-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-08
D · Potential for more than minimal harm
2023-03-16
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-05-08
Penalties and ownership
What sits behind the stars
$4,545
2023-11-06
Fine
Fine · fine $4,545
Fine
$4,545
2023-10-30
Fine
Fine · fine $4,545
Fine
$4,545
2023-10-23
Fine
Fine · fine $4,545
Fine
$4,545
2023-10-17
Fine
Fine · fine $4,545
Fine
$4,196
2023-10-10
Fine
Fine · fine $4,196
Fine
$3,846
2023-10-02
Fine
Fine · fine $3,846
Fine
$3,496
2023-09-25
Fine
Fine · fine $3,496
Fine
$3,147
2023-09-18
Fine
Fine · fine $3,147
Fine
$2,797
2023-09-11
Fine
Fine · fine $2,797
Fine
$2,447
2023-09-05
Fine
Fine · fine $2,447
Fine
$2,098
2023-08-28
Fine
Fine · fine $2,098
Fine
$1,748
2023-08-21
Fine
Fine · fine $1,748
Fine
$3,145
2023-07-31
Fine
Fine · fine $3,145
Fine
Ownership
Living Services Foundation
5% Or Greater Direct Ownership Interest · Organization
Gleason, Jennifer
Operational/Managerial Control · Individual
Gleason, Jennifer
Corporate Officer · Individual
Kamstra, Dennis
Operational/Managerial Control · Individual
Kamstra, Dennis
Corporate Director · Individual
Living Services Foundation
Operational/Managerial Control · Organization
Living Services Foundation/Mora, LLC
5% Or Greater Mortgage Interest · Organization
Pakonen, Rodney
Corporate Director · Individual
Peterson, Jennifer
W-2 Managing Employee · Individual
Sanders, Paul
Corporate Director · Individual
Sundberg, Robert
Corporate Director · Individual
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