Cycle 1
Health 2025-03-20 · Fire 2025-03-20
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Woodbury, MN
St Therese Of Woodbury Llc
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
7555 Bailey Road, Woodbury, MN
(651) 209-9100
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
56
Certified beds
Average residents
53
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Saint Therese Senior Communities
Operator or chain grouping
Approved since
2016-09-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
4 facilities
Chain averages 5 overall / 4 health / 5 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
1.80
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.54
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.24
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.58
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
2.34
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.07
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
1.29
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.23
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.81
CMS adjusted RN staffing hours
Adjusted total hours
4.62
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,510
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
56.06
Composite VBP score used to determine payment impact.
Payment multiplier
1.0111
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.15
Baseline 23.08% · Performance 21.48% · Measure score 2.15 · Achievement 0 · Improvement 2.15
Healthcare-associated infections
8.38
Baseline 5.19% · Performance 5.33% · Measure score 8.38 · Achievement 8.38 · Improvement 0
Total nurse turnover
6.01
Baseline 34.62% · Performance 39.13% · Measure score 6.01 · Achievement 6.01 · Improvement 0
Adjusted total nurse staffing
5.89
Baseline 5.37 hours · Performance 4.75 hours · Measure score 5.89 · Achievement 5.89 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.69% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 405 · Observed rate 7.41% · Lower 95% interval 7.18% |
| Discharge to community | 74.19% |
50.57%
23.6 pts better
|
Better than the National Rate · Eligible stays 406 · Observed rate 75.12% · Lower 95% interval 70.43% |
| Medicare spending per beneficiary | 0.72 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.07% |
95.27%
2.8 pts better
|
Numerator 254 · Denominator 259 |
| Falls with major injury | 0.77% |
0.77%
About the same
|
Numerator 2 · Denominator 259 |
| Discharge self-care score | 57.5% |
53.69%
3.8 pts better
|
Numerator 115 · Denominator 200 |
| Discharge mobility score | 45% |
50.94%
5.9 pts worse
|
Numerator 90 · Denominator 200 |
| Pressure ulcers or injuries, new or worsened | 3.49% |
2.29%
1.2 pts worse
|
Numerator 9 · Denominator 258 · Adjusted rate 4.82% |
| Healthcare-associated infections requiring hospitalization | 5.33% |
7.12%
1.8 pts better
|
No Different than the National Rate · Eligible stays 224 · Observed rate 2.68% · Lower 95% interval 3.12% |
| Staff COVID-19 vaccination coverage | 17.08% |
8.2%
8.9 pts better
|
Numerator 48 · Denominator 281 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 58.5% |
56.45%
2 pts better
|
Numerator 117 · Denominator 200 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 48 · Denominator 48 |
| Transfer of health information to patient | 99.49% |
96.28%
3.2 pts better
|
Numerator 197 · Denominator 198 |
| Resident COVID-19 vaccinations up to date | 57.34% |
25.2%
32.1 pts better
|
Numerator 82 · Denominator 143 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
97.3%
0.3 pts worse
|
93.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 97.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
3.9%
2.4 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.7% |
4.3%
2.6 pts better
|
11.4%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.7% |
| 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 · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.2% |
12.4%
8.2 pts better
|
19.6%
15.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.5% |
17.5%
8 pts better
|
16.7%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.5% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.6% |
18.6%
About the same
|
14.9%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.6% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.1% |
2.6%
0.5 pts worse
|
1.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.1% · 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 · 4Q avg 28.8% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
5.4%
1.5 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.7% |
88.6%
5.9 pts worse
|
81.7%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 66.0% · Q2 82.0% · Q3 91.0% · Q4 91.2% · 4Q avg 82.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.2% |
14.0%
2.8 pts better
|
12.0%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.2% · Observed 10.2% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.9%
1.4 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.4% · Q3 0.5% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.8% |
82.7%
3.1 pts better
|
79.7%
6.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.3% |
23.1%
6.2 pts worse
|
23.9%
5.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.3% · Observed 24.7% · Expected 20.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-23 · Fire 2024-05-23
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Cycle 3
Health 2023-07-27 · Fire 2023-07-27
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-20
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 2025-04-24
F · Potential for more than minimal harm
2025-03-20
K930 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper storage of liquid oxygen.
Corrected 2025-04-24
F · Potential for more than minimal harm
2024-05-23
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-06-25
F · Potential for more than minimal harm
2024-05-23
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-06-25
F · Potential for more than minimal harm
2024-05-23
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-06-25
F · Potential for more than minimal harm
2024-05-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-25
F · Potential for more than minimal harm
2024-05-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-25
F · Potential for more than minimal harm
2024-05-23
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-05-23
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-06-25
F · Potential for more than minimal harm
2023-07-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-18
F · Potential for more than minimal harm
2023-07-27
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-08-16
F · Potential for more than minimal harm
2023-07-27
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-09-26
F · Potential for more than minimal harm
2023-07-27
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-09-15
F · Potential for more than minimal harm
2023-07-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-09-01
F · Potential for more than minimal harm
2023-07-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-09-15
E · Potential for more than minimal harm
2023-07-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-07-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-08
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-20
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 2025-04-22
D · Potential for more than minimal harm
2025-03-20
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-20
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 2025-04-22
D · Potential for more than minimal harm
2025-03-20
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-20
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-04-22
G · Actual harm
2024-09-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-09-17
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-09-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-14
E · Potential for more than minimal harm
2024-05-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-05-23
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-05-23
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 2024-06-25
D · Potential for more than minimal harm
2024-05-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-05-23
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 2024-06-25
D · Potential for more than minimal harm
2024-05-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-25
D · Potential for more than minimal harm
2023-10-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-13
D · Potential for more than minimal harm
2023-07-27
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-09-21
D · Potential for more than minimal harm
2023-07-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-21
D · Potential for more than minimal harm
2023-07-27
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 2023-09-21
D · Potential for more than minimal harm
2023-07-27
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-09-21
D · Potential for more than minimal harm
2023-07-10
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-06-13
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 2023-08-01
D · Potential for more than minimal harm
2023-06-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-01
Penalties and ownership
What sits behind the stars
$0
2024-09-17
Payment Denial
Payment Denial · denial start 2024-10-17 · 4 days
4 day denial
$0
2023-06-13
Payment Denial
Payment Denial · denial start 2023-09-13 · 13 days
13 day denial
Ownership
Saint Therese
5% Or Greater Indirect Ownership Interest · Organization
Saint Therese Communities
5% Or Greater Direct Ownership Interest · Organization
Abbott, Craig
Corporate Director · Individual
Abbott, Craig
Corporate Officer · Individual
Gerland, Samantha
Operational/Managerial Control · Individual
Gillespie, Joseph
Corporate Director · Individual
Herb, Mary
Corporate Director · Individual
Hoffmann, David
Corporate Director · Individual
Hoffmann, David
Corporate Officer · Individual
Horstmann, Steven
Corporate Director · Individual
Keelin, Anthony
Operational/Managerial Control · Individual
Krenn, David
Corporate Director · Individual
Mccluskey, Patricia
Corporate Director · Individual
Mccrossan, Jane
Corporate Director · Individual
Meads, Steven
Corporate Director · Individual
Parmar, Mona
Corporate Director · Individual
Saint Therese
Operational/Managerial Control · Organization
Saint Therese Communities
Operational/Managerial Control · Organization
Saint Therese Management Services, LLC
Operational/Managerial Control · Organization
Shelangoski, Cal
Corporate Officer · Individual
Taffe, Patrick
Corporate Director · Individual
Wornson, Kathryn
Corporate Director · Individual
Wornson, Kathryn
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Woodbury Health Care Center
Woodbury, MN
1-star overall rating with 1-star inspections with $26,685 in total fines with 12 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#2
Norris Square
Cottage Grove, MN
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Woodlyn Heights Healthcare Center
Inver Grove Heights, MN
1-star overall rating with 1-star inspections with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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