Cycle 1
Health 2025-07-31 · Fire 2025-07-31
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Northfield, MN
Three Links Care Center
4-star overall rating with 3-star inspections with $12,649 in total fines with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
815 Forest Avenue, Northfield, MN
(507) 664-8800
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
92
Certified beds
Average residents
74
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
St. Francis Health Services
Operator or chain grouping
Approved since
1987-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 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
Staffing
Hours and turnover
RN hours / resident day
1.11
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.67
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.63
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.41
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.78
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
0.57
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.16
CMS adjusted RN staffing hours
Adjusted total hours
4.60
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
37%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,205
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51
Composite VBP score used to determine payment impact.
Payment multiplier
1.0053
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.59
Baseline 17.77% · Performance 18.84% · Measure score 5.59 · Achievement 5.59 · Improvement 0
Healthcare-associated infections
6.25
Baseline 5.41% · Performance 5.97% · Measure score 6.25 · Achievement 6.25 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
3.46
Baseline 5.24 hours · Performance 4.06 hours · Measure score 3.46 · Achievement 3.46 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.17% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 75 · Observed rate 8% · Lower 95% interval 6.86% |
| Discharge to community | 62.88% |
50.57%
12.3 pts better
|
No Different than the National Rate · Eligible stays 72 · Observed rate 61.11% · Lower 95% interval 49.81% |
| Medicare spending per beneficiary | 0.67 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 97.85% |
95.27%
2.6 pts better
|
Numerator 91 · Denominator 93 |
| Falls with major injury | 1.08% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 93 |
| Discharge self-care score | 36.9% |
53.69%
16.8 pts worse
|
Numerator 31 · Denominator 84 |
| Discharge mobility score | 53.57% |
50.94%
2.6 pts better
|
Numerator 45 · Denominator 84 |
| Pressure ulcers or injuries, new or worsened | 2.15% |
2.29%
0.1 pts better
|
Numerator 2 · Denominator 93 · Adjusted rate 2.83% |
| Healthcare-associated infections requiring hospitalization | 5.97% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 0% · Lower 95% interval 3.06% |
| Staff COVID-19 vaccination coverage | 32.32% |
8.2%
24.1 pts better
|
Numerator 32 · Denominator 99 |
| Staff flu vaccination coverage | 24.29% |
42%
17.7 pts worse
|
Numerator 43 · Denominator 177 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 42 · Denominator 84 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 57 · Denominator 57 |
| Resident COVID-19 vaccinations up to date | 57.78% |
25.2%
32.6 pts better
|
Numerator 26 · Denominator 45 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.6 |
1.7
1.1 pts better
|
1.9
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
2.0
1.1 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.5 · Used in QM five-star |
| 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 95.1% · Q4 100.0% · 4Q avg 98.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.3% |
3.9%
4.4 pts worse
|
3.3%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 12.3% · Q3 8.2% · Q4 4.8% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.3% |
4.3%
2 pts better
|
11.4%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 1.9% · Q3 1.8% · Q4 1.8% · 4Q avg 2.3% |
| Percentage of long-stay residents who lose too much weight | 5.1% |
4.1%
1 pts worse
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 4.4% · Q3 7.0% · Q4 4.9% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.0% |
12.4%
5.6 pts worse
|
19.6%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 20.0% · Q3 12.0% · Q4 20.0% · 4Q avg 18.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.1% |
17.5%
10.4 pts better
|
16.7%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 5.6% · Q3 7.5% · Q4 5.6% · 4Q avg 7.1% · 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 | 29.4% |
22.5%
6.9 pts worse
|
16.3%
13.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.3% · Q2 23.4% · Q3 33.2% · Q4 26.0% · 4Q avg 29.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.7% |
18.6%
1.1 pts worse
|
14.9%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 16.3% · Q3 28.3% · Q4 13.6% · 4Q avg 19.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
2.3%
0.8 pts better
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.2% · Q4 3.8% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
2.6%
0.6 pts better
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.1% · Q3 0.0% · Q4 1.6% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.4% |
24.8%
2.6 pts worse
|
19.8%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.9% · Q2 20.9% · Q3 32.6% · Q4 20.3% · 4Q avg 27.4% |
| 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 5.7% · Q2 10.0% · Q3 6.6% · Q4 7.9% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
88.6%
8.4 pts better
|
81.7%
15.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.6% · Q2 95.6% · Q3 95.8% · Q4 99.0% · 4Q avg 97.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.8% |
14.0%
3.2 pts better
|
12.0%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.8% · Observed 9.8% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.9%
1.5 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.6% |
82.7%
11.9 pts better
|
79.7%
14.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.8% |
23.1%
2.3 pts better
|
23.9%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.8% · Observed 14.6% · Expected 16.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-23 · Fire 2024-05-23
8 health deficiencies
Top issue: Resident Rights (4 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2023-08-17 · Fire 2023-08-17
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-31
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-09-11
F · Potential for more than minimal harm
2025-07-31
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-09-11
F · Potential for more than minimal harm
2025-07-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-11
F · Potential for more than minimal harm
2025-07-31
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-09-11
C · Minimal harm
2025-07-31
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-09-11
C · Minimal harm
2025-07-31
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-09-11
C · Minimal harm
2025-07-31
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-09-11
F · Potential for more than minimal harm
2024-05-23
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 2024-06-05
F · Potential for more than minimal harm
2024-05-23
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-05-22
F · Potential for more than minimal harm
2024-05-23
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-06-28
F · Potential for more than minimal harm
2023-08-17
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-09-29
F · Potential for more than minimal harm
2023-08-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-29
F · Potential for more than minimal harm
2023-08-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-09-29
F · Potential for more than minimal harm
2023-08-17
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-09-29
F · Potential for more than minimal harm
2023-08-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-09-29
F · Potential for more than minimal harm
2023-08-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-29
F · Potential for more than minimal harm
2023-08-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-09-29
F · Potential for more than minimal harm
2023-08-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-08-17
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-08-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-29
Inspection history
Recent health citations
J · Immediate jeopardy
2025-09-19
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 2025-09-12
D · Potential for more than minimal harm
2025-07-31
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 2025-08-29
D · Potential for more than minimal harm
2025-07-31
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-08-23
D · Potential for more than minimal harm
2025-07-31
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 2025-08-23
D · Potential for more than minimal harm
2025-07-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-23
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 2024-07-31
D · Potential for more than minimal harm
2024-05-23
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 2024-07-31
D · Potential for more than minimal harm
2024-05-23
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2024-07-31
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 2024-07-31
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 2024-07-31
D · Potential for more than minimal harm
2024-05-23
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-05-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-31
B · Minimal harm
2024-05-23
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2024-07-31
J · Immediate jeopardy
2023-10-13
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 2023-10-03
E · Potential for more than minimal harm
2023-08-17
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 2023-09-29
D · Potential for more than minimal harm
2023-08-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-09-29
Penalties and ownership
What sits behind the stars
$12,649
2023-08-17
Fine
Fine · fine $12,649
Fine
Ownership
Chambers, Mari
Operational/Managerial Control · Individual
Chambers, Mari
Corporate Officer · Individual
Dripps, Daniel
Corporate Director · Individual
Ehlers, Douglas
Corporate Director · Individual
Goodnough, Jennifer
Corporate Director · Individual
Gramm, Timothy
Corporate Director · Individual
Letendre, Paul
Corporate Director · Individual
Letich, Elizabeth
Operational/Managerial Control · Individual
Luetmer, John
Corporate Director · Individual
Mittal, Vikas
Contracted Managing Employee · Individual
Nelson, Patrick
Corporate Director · Individual
Peterson-Devries, Camilla
Operational/Managerial Control · Individual
Peterson-Devries, Camilla
Corporate Officer · Individual
Raw, Carol
Operational/Managerial Control · Individual
Raw, Carol
Corporate Director · Individual
Raw, Carol
Corporate Officer · Individual
Relcosky, Joan
Corporate Director · Individual
Rentz, Paul
Corporate Director · Individual
Schneider, Todd
Corporate Director · Individual
Seales, Jennifer
Corporate Director · Individual
Sperr, Tamela
Corporate Director · Individual
Wagner, Sherry
W-2 Managing Employee · Individual
Wiese, Lorraine
Corporate Director · Individual
Nearby options
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Faribault, MN
1-star overall rating with 1-star inspections with 21 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Trinity Care Center
Farmington, MN
5-star overall rating with 3-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Apple Valley Village Health Care Center
Apple Valley, MN
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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