Cycle 1
Health 2024-05-30 · Fire 2024-05-30
13 health deficiencies
Top issue: Administration (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Zumbrota, MN
Zumbrota Care Center
2-star overall rating with 1-star inspections with 13 recent health deficiencies
433 Mill Street, Zumbrota, MN
(507) 732-8400
Overall
2 / 5
CMS overall stars
Health inspections
1 / 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
40
Certified beds
Average residents
33
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
St. Francis Health Services
Operator or chain grouping
Approved since
1986-12-01
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
1.53
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.36
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.00
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
1.89
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.12
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
1.00
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
1.86
CMS adjusted RN staffing hours
Adjusted total hours
4.75
CMS adjusted total nurse staffing hours
Case-mix index
1.12
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,808
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.64
Composite VBP score used to determine payment impact.
Payment multiplier
0.9866
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
0.44
Baseline 68.18% · Performance 64.10% · Measure score 0.44 · Achievement 0 · Improvement 0.44
Adjusted total nurse staffing
5.89
Baseline 5.11 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 | 9.77% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 3.03% · Lower 95% interval 6.54% |
| Discharge to community | 47.09% |
50.57%
3.5 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 41.67% · Lower 95% interval 33.31% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 36 · Denominator 36 |
| Falls with major injury | 2.78% |
0.77%
2 pts worse
|
Numerator 1 · Denominator 36 |
| Discharge self-care score | 75% |
53.69%
21.3 pts better
|
Numerator 21 · Denominator 28 |
| Discharge mobility score | 71.43% |
50.94%
20.5 pts better
|
Numerator 20 · Denominator 28 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 36 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 4.55% |
8.2%
3.6 pts worse
|
Numerator 3 · Denominator 66 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 85.71% |
56.45%
29.3 pts better
|
Numerator 24 · Denominator 28 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · 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 | 8.5% |
3.9%
4.6 pts worse
|
3.3%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 10.0% · Q3 10.3% · Q4 10.3% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.9% |
4.3%
0.4 pts better
|
11.4%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.8% · Q3 3.8% · Q4 3.7% · 4Q avg 3.9% |
| Percentage of long-stay residents who lose too much weight | 2.5% |
4.1%
1.6 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.1% · 4Q avg 2.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.5% |
12.4%
2.9 pts better
|
19.6%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 12.5% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.0% |
17.5%
14.5 pts better
|
16.7%
13.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.0% · 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 | 15.9% |
22.5%
6.6 pts better
|
16.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.4% |
18.6%
2.8 pts worse
|
14.9%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 37.5% · 4Q avg 21.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 8.0% |
2.3%
5.7 pts worse
|
1.0%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 9.8% · Q3 7.7% · Q4 11.1% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.5% |
2.6%
0.9 pts worse
|
1.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 6.9% · Q4 3.4% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.2% |
24.8%
1.4 pts worse
|
19.8%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 34.2% · Q3 19.2% · Q4 24.9% · 4Q avg 26.2% |
| Percentage of long-stay residents with pressure ulcers | 0.5% |
5.4%
4.9 pts better
|
5.1%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.1% · 4Q avg 0.5% · 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% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.9% |
1.9%
2 pts worse
|
1.6%
2.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
82.7%
17.3 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-10 · Fire 2023-08-10
9 health deficiencies
Top issue: Administration (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-03-23 · Fire 2022-03-23
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-02
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 2025-12-04
D · Potential for more than minimal harm
2025-11-26
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 2025-12-01
D · Potential for more than minimal harm
2025-11-26
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-12-01
F · Potential for more than minimal harm
2025-08-07
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 2025-09-19
J · Immediate jeopardy
2025-05-27
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 2025-06-30
F · Potential for more than minimal harm
2025-05-27
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2025-05-29
F · Potential for more than minimal harm
2025-05-27
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-06-16
D · Potential for more than minimal harm
2025-05-27
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 2025-06-27
D · Potential for more than minimal harm
2025-05-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-20
C · Minimal harm
2025-05-27
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-06-16
C · Minimal harm
2025-05-27
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 2025-06-19
F · Potential for more than minimal harm
2024-05-30
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-07-02
F · Potential for more than minimal harm
2024-05-30
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 2024-07-02
F · Potential for more than minimal harm
2023-08-10
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 2023-10-20
F · Potential for more than minimal harm
2023-08-10
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-10-20
F · Potential for more than minimal harm
2023-08-10
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2023-10-20
F · Potential for more than minimal harm
2023-08-10
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-10-20
F · Potential for more than minimal harm
2023-08-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-20
F · Potential for more than minimal harm
2023-08-10
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-10-20
F · Potential for more than minimal harm
2023-08-10
F924 · Environmental Deficiencies
Health
Put firmly secured handrails on each side of hallways.
Corrected 2023-10-20
E · Potential for more than minimal harm
2023-08-10
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 2023-10-20
D · Potential for more than minimal harm
2023-08-10
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-10-20
F · Potential for more than minimal harm
2022-03-23
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 2022-04-30
B · Minimal harm
2022-03-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-04-30
Penalties and ownership
What sits behind the stars
Ownership
St. Francis Health Services Of Morris, Inc
5% Or Greater Direct Ownership Interest · Organization
Allen, Scot
Operational/Managerial Control · Individual
Allen, Scot
W-2 Managing Employee · Individual
Berlinger, Mark
Corporate Director · Individual
Dripps, Daniel
Corporate Director · Individual
Erdman, Katie
Corporate Director · Individual
Heltemes, Vivian
Corporate Director · Individual
Hoffman, Luverne
Operational/Managerial Control · Individual
Hoffman, Luverne
Corporate Director · Individual
Hoffman, Luverne
W-2 Managing Employee · Individual
Knobloch, Stephanie
Corporate Director · Individual
Lienemann, Steven
Corporate Director · Individual
Meichsner, Elizabeth
Corporate Director · Individual
Moncrief, William
Operational/Managerial Control · Individual
Moncrief, William
Corporate Officer · Individual
Moncrief, William
W-2 Managing Employee · Individual
Raw, Carol
Operational/Managerial Control · Individual
Raw, Carol
Corporate Director · Individual
Raw, Carol
W-2 Managing Employee · Individual
Riley, Carla
Corporate Director · Individual
Schmidgall, Neil
Corporate Director · Individual
Schneider, Todd
Corporate Director · Individual
St. Francis Health Services Of Morris, Inc
Operational/Managerial Control · Organization
Thooft, Alyssa
Corporate Director · Individual
Vazquez, Monserrat
Corporate Director · Individual
Nearby options
Other facilities in reach
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#2
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Rochester, MN
1-star overall rating with 1-star inspections with Special Focus status with 17 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Madonna Towers Of Rochester Inc
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3-star overall rating with 3-star inspections with $10,196 in total fines with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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