Cycle 1
Health 2025-02-13 · Fire 2025-02-13
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Canby, MN
Sylvan Court
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
112 St Olaf Avenue South, Canby, MN
(507) 223-7277
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
53
Certified beds
Average residents
43
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Sanford Health Good Samaritan (Prospera)
Operator or chain grouping
Approved since
1987-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
4 facilities
Chain averages 3 overall / 2 health / 4 staffing / 3 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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.73
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.70
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.75
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.19
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.74
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.84
CMS adjusted RN staffing hours
Adjusted total hours
4.78
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
58%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
720
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
64.89
Composite VBP score used to determine payment impact.
Payment multiplier
1.0193
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
8.67
Baseline 45.61% · Performance 28.26% · Measure score 8.67 · Achievement 8.67 · Improvement 7.86
Adjusted total nurse staffing
4.31
Baseline 5.03 hours · Performance 4.30 hours · Measure score 4.31 · Achievement 4.31 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 9 · 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 7 · 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 8 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 8 · 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 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 177 |
| Staff flu vaccination coverage | 92.94% |
42%
50.9 pts better
|
Numerator 79 · Denominator 85 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 4 · 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 | 98.8% |
97.3%
1.5 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.1% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 98.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.7% |
96.1%
1.6 pts better
|
95.5%
2.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.8% |
3.9%
2.9 pts worse
|
3.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 7.5% · Q3 7.3% · Q4 2.6% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.2% |
4.3%
0.9 pts worse
|
11.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 10.3% · Q3 2.5% · Q4 0.0% · 4Q avg 5.2% |
| Percentage of long-stay residents who lose too much weight | 4.6% |
4.1%
0.5 pts worse
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 7.9% · Q3 7.7% · Q4 0.0% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.1% |
12.4%
4.7 pts worse
|
19.6%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 18.4% · Q3 17.9% · Q4 16.7% · 4Q avg 17.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.5% |
17.5%
4 pts better
|
16.7%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 15.6% · Q3 15.8% · Q4 12.1% · 4Q avg 13.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.6% |
0.1%
0.5 pts worse
|
0.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents whose ability to walk independently worsened | 29.8% |
22.5%
7.3 pts worse
|
16.3%
13.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.8% |
18.6%
13.2 pts worse
|
14.9%
16.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.2% · Q2 20.6% · Q3 45.7% · Q4 17.2% · 4Q avg 31.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
2.3%
1.6 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.7% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.6%
2.6 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 31.3% |
24.8%
6.5 pts worse
|
19.8%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.7% · Q2 34.1% · Q3 20.5% · Q4 33.8% · 4Q avg 31.3% |
| Percentage of long-stay residents with pressure ulcers | 1.3% |
5.4%
4.1 pts better
|
5.1%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 2.7% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
88.6%
11.4 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-01 · Fire 2024-05-01
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-05-10 · Fire 2023-05-10
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-02-13
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.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-02-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-02-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-13
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-02-13
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 2025-03-14
D · Potential for more than minimal harm
2025-02-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-14
D · Potential for more than minimal harm
2024-05-01
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 2024-06-12
D · Potential for more than minimal harm
2024-02-14
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 2024-03-18
D · Potential for more than minimal harm
2024-02-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-03-18
Penalties and ownership
What sits behind the stars
Ownership
Sanford
5% Or Greater Indirect Ownership Interest · Organization
Sanford Health
5% Or Greater Direct Ownership Interest · Organization
Cain, James
Corporate Director · Individual
Dulski, Karin
W-2 Managing Employee · Individual
Engbrecht, Wesley
Corporate Director · Individual
Gassen, William
Corporate Director · Individual
Gassen, William
Corporate Officer · Individual
Gassen, William
W-2 Managing Employee · Individual
Gulsvig, Neil
Corporate Director · Individual
Jacobs, Donald
Corporate Director · Individual
Lundeen, Mark
Corporate Director · Individual
Marlette, William
Corporate Officer · Individual
Marlette, William
W-2 Managing Employee · Individual
Molbert, Lauris
Corporate Director · Individual
Morrison, Tony
Corporate Director · Individual
Morrison, Tony
W-2 Managing Employee · Individual
Munson, Jolyn
W-2 Managing Employee · Individual
North, Andrew
Corporate Director · Individual
Swenson, Stephanie
W-2 Managing Employee · Individual
Teiken, Brent
Corporate Director · Individual
Ventling-Herrmann, Marnie
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Hendricks Community Hospital
Hendricks, MN
2-star overall rating with 2-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Johnson Memorial Hosp & Home
Dawson, MN
3-star overall rating with 2-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Madison Healthcare Services
Madison, MN
3-star overall rating with 4-star inspections with $10,036 in total fines with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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