Cycle 1
Health 2025-12-03 · Fire 2025-12-03
12 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Albert Lea, MN
St Johns On Fountain Lake
3-star overall rating with 2-star inspections with $16,448 in total fines with 12 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1771 Eagle View Circle, Albert Lea, MN
(507) 373-2040
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
84
Certified beds
Average residents
68
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2018-03-29
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
0.97
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.91
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.88
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.98
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.34
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.10
CMS adjusted RN staffing hours
Adjusted total hours
5.57
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
28%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
29%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,279
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.09
Composite VBP score used to determine payment impact.
Payment multiplier
0.9983
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.07% · Performance 21.22% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.93
Baseline 5.38% · Performance 6.66% · Measure score 3.93 · Achievement 3.93 · Improvement 0
Total nurse turnover
6.29
Baseline 36.84% · Performance 37.96% · Measure score 6.29 · Achievement 6.29 · Improvement 0
Adjusted total nurse staffing
7.81
Baseline 5.25 hours · Performance 5.30 hours · Measure score 7.81 · Achievement 7.81 · Improvement 0.39
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.84% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 87 · Observed rate 12.64% · Lower 95% interval 7.88% |
| Discharge to community | 58.83% |
50.57%
8.3 pts better
|
No Different than the National Rate · Eligible stays 79 · Observed rate 51.9% · Lower 95% interval 46.85% |
| Medicare spending per beneficiary | 0.75 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 5.33% |
95.27%
89.9 pts worse
|
Numerator 4 · Denominator 75 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 75 |
| Discharge self-care score | 61.82% |
53.69%
8.1 pts better
|
Numerator 34 · Denominator 55 |
| Discharge mobility score | 45.45% |
50.94%
5.5 pts worse
|
Numerator 25 · Denominator 55 |
| Pressure ulcers or injuries, new or worsened | 2.67% |
2.29%
0.4 pts worse
|
Numerator 2 · Denominator 75 · Adjusted rate 2.73% |
| Healthcare-associated infections requiring hospitalization | 6.66% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 54 · Observed rate 5.56% · Lower 95% interval 3.53% |
| Staff COVID-19 vaccination coverage | 2.53% |
8.2%
5.7 pts worse
|
Numerator 5 · Denominator 198 |
| Staff flu vaccination coverage | 24.23% |
42%
17.8 pts worse
|
Numerator 47 · Denominator 194 |
| Discharge function score | 74.55% |
56.45%
18.1 pts better
|
Numerator 41 · Denominator 55 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 40 · Denominator 40 |
| Resident COVID-19 vaccinations up to date | 37.5% |
25.2%
12.3 pts better
|
Numerator 15 · Denominator 40 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.7
0.4 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.6 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
2.0
0.1 pts better
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.0 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.1% |
97.3%
1.2 pts worse
|
93.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 87.9% · Q3 96.5% · Q4 100.0% · 4Q avg 96.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
96.1%
2.4 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.9% |
3.9%
3 pts worse
|
3.3%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 8.6% · Q3 8.8% · Q4 3.6% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
4.3%
3.8 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 2.1% |
4.1%
2 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 0.0% · Q3 2.2% · Q4 0.0% · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.9% |
12.4%
4.5 pts better
|
19.6%
11.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 10.6% · Q3 8.7% · Q4 6.5% · 4Q avg 7.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.7% |
17.5%
1.8 pts better
|
16.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 12.2% · Q3 16.7% · Q4 14.3% · 4Q avg 15.7% · 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 | 29.9% |
22.5%
7.4 pts worse
|
16.3%
13.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.6% · Q2 33.6% · 4Q avg 29.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.8% |
18.6%
2.8 pts better
|
14.9%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 23.9% · Q3 6.7% · Q4 11.1% · 4Q avg 15.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
2.3%
0.7 pts better
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 1.1% · Q3 1.3% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.9% |
2.6%
1.3 pts worse
|
1.7%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.4% · Q3 3.5% · Q4 5.5% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.8% |
24.8%
1 pts worse
|
19.8%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.0% · Q2 29.4% · Q3 23.7% · Q4 22.9% · 4Q avg 25.8% |
| Percentage of long-stay residents with pressure ulcers | 7.7% |
5.4%
2.3 pts worse
|
5.1%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 11.6% · Q3 7.1% · Q4 1.6% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.2% |
88.6%
2.6 pts better
|
81.7%
9.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 91.8% · Q3 86.6% · Q4 88.5% · 4Q avg 91.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.2% |
14.0%
2.2 pts worse
|
12.0%
4.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.2% · Observed 16.2% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.9%
0.8 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.0% |
82.7%
13.3 pts better
|
79.7%
16.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.1% |
23.1%
2 pts better
|
23.9%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.1% · Observed 21.2% · Expected 24.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-06 · Fire 2024-11-06
9 health deficiencies
Top issue: Infection Control (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2024-01-10 · Fire 2024-01-10
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-03
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2026-01-08
F · Potential for more than minimal harm
2025-12-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2026-01-08
F · Potential for more than minimal harm
2025-12-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-01-08
F · Potential for more than minimal harm
2025-12-03
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2026-01-08
D · Potential for more than minimal harm
2025-12-03
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2026-01-08
D · Potential for more than minimal harm
2025-12-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-08
F · Potential for more than minimal harm
2024-11-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-12
F · Potential for more than minimal harm
2024-11-06
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-12-12
F · Potential for more than minimal harm
2024-11-06
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-12-12
F · Potential for more than minimal harm
2024-11-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-12
F · Potential for more than minimal harm
2024-11-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-12
E · Potential for more than minimal harm
2024-11-06
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-12-12
C · Minimal harm
2024-11-06
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-12-12
F · Potential for more than minimal harm
2024-01-10
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-02-08
F · Potential for more than minimal harm
2024-01-10
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 2024-02-08
F · Potential for more than minimal harm
2024-01-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-02-08
E · Potential for more than minimal harm
2024-01-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-08
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-03
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 2026-01-08
D · Potential for more than minimal harm
2025-12-03
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2026-01-08
D · Potential for more than minimal harm
2025-12-03
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 2026-01-08
D · Potential for more than minimal harm
2025-12-03
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2026-01-08
D · Potential for more than minimal harm
2025-12-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-01-08
D · Potential for more than minimal harm
2025-12-03
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 2026-01-08
D · Potential for more than minimal harm
2025-12-03
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2026-01-08
D · Potential for more than minimal harm
2025-12-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2026-01-08
D · Potential for more than minimal harm
2025-12-03
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2026-01-08
J · Immediate jeopardy
2025-08-06
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-07-21
D · Potential for more than minimal harm
2025-08-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-08-06
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 2025-09-03
F · Potential for more than minimal harm
2024-11-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-12
E · Potential for more than minimal harm
2024-11-06
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 2024-12-12
D · Potential for more than minimal harm
2024-11-06
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 2024-12-12
D · Potential for more than minimal harm
2024-11-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-12
D · Potential for more than minimal harm
2024-11-06
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 2024-12-12
D · Potential for more than minimal harm
2024-09-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-10
G · Actual harm
2024-07-26
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 2024-08-03
D · Potential for more than minimal harm
2024-04-17
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 2024-05-10
D · Potential for more than minimal harm
2024-04-17
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 2024-05-10
G · Actual harm
2024-01-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-05
F · Potential for more than minimal harm
2024-01-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-05
E · Potential for more than minimal harm
2024-01-10
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-02-05
D · Potential for more than minimal harm
2024-01-10
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-02-05
D · Potential for more than minimal harm
2024-01-10
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-02-05
D · Potential for more than minimal harm
2024-01-10
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-02-05
D · Potential for more than minimal harm
2023-09-20
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-09-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-09-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-28
Penalties and ownership
What sits behind the stars
$16,448
2024-07-26
Fine
Fine · fine $16,448
Fine
Ownership
City Of Hayward Minnesota
5% Or Greater Mortgage Interest · Organization
Enderson, Joshua
Corporate Director · Individual
Erickson, Joel
Corporate Director · Individual
Irvine, Larry
Corporate Director · Individual
Kenison, Debra
Corporate Director · Individual
Mallon, Duane
W-2 Managing Employee · Individual
Nelson, Donna
Corporate Officer · Individual
Reindal, Charles
Corporate Director · Individual
Skov, Lance
Corporate Officer · Individual
Spates, Scot
W-2 Managing Employee · Individual
United States Department Of Agriculture - Rural Development
5% Or Greater Mortgage Interest · Organization
Zenk, Steven
Corporate Director · Individual
Nearby options
Other facilities in reach
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Thorne Crest Retirement Center
Albert Lea, MN
1-star overall rating with 1-star inspections with $43,082 in total fines with 21 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Good Samaritan Society - Albert Lea
Albert Lea, MN
4-star overall rating with 3-star inspections with $26,685 in total fines with 4 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
New Richland Care Center
New Richland, MN
1-star overall rating with 1-star inspections with $122,605 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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