Cycle 1
Health 2025-07-30 · Fire 2025-07-30
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
9 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Morris, MN
West Wind Village
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
1001 Scotts Avenue, Morris, MN
(320) 589-7900
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
45
Certified beds
Average residents
40
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
St. Francis Health Services
Operator or chain grouping
Approved since
1983-09-01
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
0.73
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.35
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
3.89
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.38
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.90
CMS adjusted RN staffing hours
Adjusted total hours
4.82
CMS adjusted total nurse staffing hours
Case-mix index
1.10
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,644
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.13
Composite VBP score used to determine payment impact.
Payment multiplier
0.9921
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
4.19
Baseline 44.74% · Performance 46.55% · Measure score 4.19 · Achievement 4.19 · Improvement 0
Adjusted total nurse staffing
3.64
Baseline 4.52 hours · Performance 4.11 hours · Measure score 3.64 · Achievement 3.64 · 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 43 · Observed rate 9.3% · Lower 95% interval 6.42% |
| Discharge to community | 51.66% |
50.57%
1.1 pts better
|
No Different than the National Rate · Eligible stays 40 · Observed rate 52.5% · Lower 95% interval 40.07% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 31 · Denominator 31 |
| Falls with major injury | 3.23% |
0.77%
2.5 pts worse
|
Numerator 1 · Denominator 31 |
| Discharge self-care score | 54.55% |
53.69%
0.9 pts better
|
Numerator 12 · Denominator 22 |
| Discharge mobility score | 63.64% |
50.94%
12.7 pts better
|
Numerator 14 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 31 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0.92% |
8.2%
7.3 pts worse
|
Numerator 1 · Denominator 109 |
| Staff flu vaccination coverage | 16.81% |
42%
25.2 pts worse
|
Numerator 19 · Denominator 113 |
| Discharge function score | 63.64% |
56.45%
7.2 pts better
|
Numerator 14 · Denominator 22 |
| 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 | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · 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 | 100.0% |
97.3%
2.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 4.5% |
3.9%
0.6 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.5% · Q3 7.5% · Q4 5.1% · 4Q avg 4.5% · 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 | 0.0% |
4.1%
4.1 pts better
|
5.4%
5.4 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 received an antianxiety or hypnotic medication | 8.2% |
12.4%
4.2 pts better
|
19.6%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 5.6% · Q3 9.4% · Q4 11.8% · 4Q avg 8.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.0% |
17.5%
11.5 pts better
|
16.7%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 7.1% · Q3 6.9% · Q4 3.1% · 4Q avg 6.0% · 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 | 23.4% |
22.5%
0.9 pts worse
|
16.3%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.9% |
18.6%
10.3 pts worse
|
14.9%
14 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 15.2% · Q3 37.9% · Q4 40.0% · 4Q avg 28.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.0% |
2.3%
0.7 pts worse
|
1.0%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 2.7% · Q3 3.8% · Q4 2.3% · 4Q avg 3.0% · 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 | 29.9% |
24.8%
5.1 pts worse
|
19.8%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.5% · Q2 29.0% · Q3 26.7% · Q4 25.9% · 4Q avg 29.9% |
| Percentage of long-stay residents with pressure ulcers | 0.7% |
5.4%
4.7 pts better
|
5.1%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · 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 · Q1 100.0% · 4Q avg 100.0% |
| 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 · 4Q avg 0.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-01 · Fire 2024-05-01
4 health deficiencies
Top issue: Administration (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-07-12 · Fire 2023-07-12
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-30
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-09-30
E · Potential for more than minimal harm
2025-07-30
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 2025-09-30
E · Potential for more than minimal harm
2025-07-30
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2025-09-30
E · Potential for more than minimal harm
2025-07-30
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-09-30
E · Potential for more than minimal harm
2025-07-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-09-30
E · Potential for more than minimal harm
2025-07-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-09-30
D · Potential for more than minimal harm
2025-07-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-30
D · Potential for more than minimal harm
2025-07-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-09-30
D · Potential for more than minimal harm
2025-07-30
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 2025-09-30
D · Potential for more than minimal harm
2024-05-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-27
D · Potential for more than minimal harm
2024-05-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-27
D · Potential for more than minimal harm
2024-05-01
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-05-27
D · Potential for more than minimal harm
2023-07-12
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-09-13
C · Minimal harm
2023-07-12
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-09-11
Inspection history
Recent health citations
G · Actual harm
2025-07-30
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 2025-08-26
D · Potential for more than minimal harm
2025-07-30
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 2025-08-26
D · Potential for more than minimal harm
2025-07-30
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 2025-08-26
F · Potential for more than minimal harm
2024-05-01
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-05-27
F · Potential for more than minimal harm
2024-05-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-27
D · Potential for more than minimal harm
2024-05-01
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-05-27
D · Potential for more than minimal harm
2024-05-01
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 2024-05-27
D · Potential for more than minimal harm
2023-07-12
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-12
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 2023-09-01
D · Potential for more than minimal harm
2023-07-12
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-09-01
Penalties and ownership
What sits behind the stars
Ownership
St. Francis Health Services Of Morris, Inc
5% Or Greater Direct Ownership Interest · Organization
Big Stone Therapies Inc
Operational/Managerial Control · Organization
Dripps, Daniel
Corporate Director · Individual
Ehlers, Douglas
Corporate Director · Individual
Eide Bailly Llp
Operational/Managerial Control · Organization
Goodnough, Jennifer
Corporate Officer · Individual
Gramm, Timothy
Corporate Director · Individual
Luetmer, John
Corporate Director · Individual
Nelson, Patrick
Corporate Director · Individual
Peterson-Devries, Camilla
Operational/Managerial Control · Individual
Peterson-Devries, Camilla
Corporate Director · Individual
Peterson-Devries, Camilla
Corporate Officer · Individual
Raw, Carol
Operational/Managerial Control · Individual
Raw, Carol
Corporate Director · Individual
Raw, Carol
Corporate Officer · Individual
Rentz, Paul
Corporate Director · Individual
Schneider, Todd
Corporate Director · Individual
St. Francis Health Services Of Morris, Inc
Operational/Managerial Control · Organization
Wiese, Lorraine
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Minnewaska Community Health Services
Starbuck, MN
1-star overall rating with 1-star inspections with $31,013 in total fines with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Barrett Care Center Inc
Barrett, MN
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Essentia Health Grace Home
Graceville, MN
4-star overall rating with 3-star inspections with 3 recent health deficiencies
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