Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- MinnesotaLowest tier among peers337 rated homes · average 3.2★
- United StatesLowest tier among peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point1★−1.8 vs MN avg
- StaffingCan add or remove a star4★−0.1 vs MN avg
- Quality measuresCan add or remove a star2★−1.2 vs MN avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersMN avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover4★Above only 22% of peersMN avg4.1★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments2★Above only 7% of peersMN avg3.2★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff4.88hrsAbove 82% of peersMN avg4.23Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only1.26hrsAbove 77% of peersMN avg1.06Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better72%Above only 3% of peersMN avg42%RN turnover73%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$184,380Above only 1% of peersMN avg$19,953Fines · denials1 · 1
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthMay 2022 – Dec 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Dec 19, 2025Cycle 1worst F · no actual harm
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Jan 23, 2026
- F732Post nurse staffing information every day.Nursing and Physician ServicesC · widespreadCorrected Jan 23, 2026
- F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Nursing and Physician ServicesF · widespreadCorrected Jan 23, 2026
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Jan 23, 2026
- F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jan 23, 2026
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jan 23, 2026
- F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Jan 23, 2026
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Jan 23, 2026
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Jan 23, 2026
Jul 18, 2025Cycle 1worst J · immediate jeopardy
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceJ · isolatedCorrected Aug 15, 2025
Jan 9, 2025Cycle 1worst F · no actual harm
- F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Feb 25, 2025
- F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Infection ControlD · isolatedCorrected Feb 25, 2025
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Feb 25, 2025
- F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Feb 25, 2025
Dec 2, 2024Cycle 2worst G · actual harm
- Ensure each residentâs drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Jan 2, 2025
- F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareG · isolatedCorrected Jan 2, 2025
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Jan 2, 2025
Nov 21, 2024Cycle 2worst D · no actual harmpayment denial
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 27, 2024
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Nov 27, 2024
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 27, 2024
Oct 26, 2023Cycle 2worst D · no actual harm
- F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy ServiceD · isolatedCorrected Nov 20, 2023
- F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected Nov 20, 2023
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Nov 20, 2023
Jul 11, 2023Cycle 3worst D · no actual harm
- F908Keep all essential equipment working safely.EnvironmentalD · isolatedCorrected Aug 1, 2023
May 25, 2023Cycle 3worst J · immediate jeopardy$184,380
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Jun 6, 2023
May 4, 2022Cycle 3worst G · actual harm
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected May 27, 2022
- F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsG · isolatedCorrected May 27, 2022
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected May 27, 2022
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined4.88hrs
- Registered nursesRN hours only1.26hrs
- Licensed practical nursesLPN hours0.56hrs
- Nurse aidesCNA hours3.06hrs
- Weekend nursingAll staff on Saturdays and Sundays4.44hrs
- Minnesota average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better72%Above only 3% of peersMN avg 42%
- RN turnoverRegistered nurses only73%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy49 certified beds · ~32 residents a day64%Above only 7% of peersMN avg 83%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $184,380In fines
- 1Fine
- 1Payment denial
- $19,953MN avg in fines
Actions on record
- Nov 21, 2024Denial of payment for new admissionsfrom Dec 28, 2024
- May 25, 2023Civil money penalty$184,380
Ownership
As filed with CMSStructure
- Ownership type
- Non profit - Corporation
- Chain
- Independent
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Gundersen Lutheran Health System INC
- Bellin Gundersen Health System INC
- Bellin Gundersen Health System INC
- Gundersen Lutheran Health System INC
- Vickie Bakalars
- Bruce Hegge
- Elizabeth Hermeier
- Charles Johnson
- Sarah Melde
- Jane Morken
- Amanda Pericak
- Kari Adank
- Gregory Tjossem
- Thomas Woahloe
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 245429 · 125 5TH AVENUE SOUTHEAST, SPRING GROVE, MN, 55974.
- Percentiles compare this facility with every rated nursing home in Minnesota and Houston County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.
