Home Inspections

Rochester nursing home inspections reveal issues ranging from ‘minimal harm’ to ‘immediate jeopardy’ for residents

The Post Bulletin reviewed 226 pages of the most recent health inspection reports of seven local nursing homes from The Centers for Medicare and Medicaid Services.

Four facilities received one-star ratings for their health inspections, two facilities received two-star ratings, and one received four stars.

Many of the reports outlined concerns classified as “minimal harm,” such as providing proper grooming for residents who are unable to shave facial hair or trim their nails. But some detailed cases of “immediate jeopardy to resident health or safety” or “actual harm” to residents, such as not adequately caring for ulcers or leaving a resident unattended for extended periods as they sat in soiled linens.

A “snapshot” in time

State agencies, such as the Minnesota Department of Health, are contracted by The Centers for Medicare and Medicaid Services to complete reviews of facilities accepting Medicare and Medicaid payments. According to the Minnesota Department of Health, the reviews examine the quality of care provided for residents, as well as equipment, staffing, policy and procedure. The department emphasizes that the reports are “a snapshot” of the facility.

Amanda Vickstrom, executive director of the Minnesota Elder Justice Center, said although the inspections do capture just a slice of life in the facility, they’re an important factor when considering the quality of care a resident would receive there. Additionally, they add necessary accountability to the space, she said.

“This is not an area that has too much oversight,” Vickstrom said.


“The flavor of the month has been infection control, and I think it will be for a long time down the road.”

– Brian Lee, executive director of Families for Better Care


The hundreds of pages of reports between seven Rochester facilities revealed similar deficiencies in areas such as communication with resident families, identifying clear policies to prevent abuse, adequately training and evaluating staff and caring for residents’ wounds.

One of the commonly cited areas of improvement for local nursing homes is infection control practices, which took on new importance since the time when most of the inspections were conducted in late 2019 or early 2020.

“The flavor of the month has been infection control, and I think it will be for a long time down the road,” said Brian Lee, executive director of Families for Better Care, a Texas nonprofit focused on raising awareness about elder care.

Nursing home leaders and eldercare advocates alike say these evaluations are one piece of the puzzle, and that other elements, such as state inspections from the Minnesota Department of Health, or investigations of complaints from families of residents, should factor in when considering the quality of a facility. Families should also visit the facility they’re considering for their loved one, said experts and regulators.

Below are the findings from The Post Bulletin’s review of the latest health inspections from each facility. The Centers for Medicare and Medicaid Services calculates a facility’s overall rating — out of five stars — by considering results of health inspections, staffing and quality of resident care measures. These three metrics are also individually scored out of five stars.

Benedictine Madonna Towers of Rochester

Madonna Towers Tuesday, May 4, 2021, in Rochester. (Joe Ahlquist / jahlquist@postbulletin.com)

Madonna Towers Tuesday, May 4, 2021, in Rochester. (Joe Ahlquist / [email protected])

Overall rating: 2 stars

Health inspections: 1 star

Staffing: 4 stars

Quality of resident care: 4 stars

Most recent report completed February 2020.

Issues identified: The risk ratings of the 23 deficiencies identified in the review of Madonna Towers of Rochester vary greatly. Those classified as having minimal harm included ensuring residents are properly groomed, reporting potential abuse or neglect in a timely manner, and improving communication with residents surrounding discharge or transfer.

Three were classified as actual harm to residents. One example the inspection uncovered was the treatment of residents’ ulcers. The resident had reportedly refused staff members’ attempts to treat the ulcers.

One practice was identified as putting a resident in immediate jeopardy. The resident was left in their room for extended periods without care, sometimes sitting in soiled linens.

“When this survey was completed last year, we took the situation very seriously and took immediate action to address the citations,” said George B. Kratee, executive director of Benedictine Living Community-Rochester, in a statement. These actions included new training and retraining of staff members, reviews and changes to caregiving processes, and increasing efforts to meet and exceed standards of care for residents.

Facility leaders submitted a corrective plan to the Minnesota Department of Health, which was accepted in March 2020. Benedictine Madonna Towers has since added new leaders to its team, Kratee said, who “with the dedicated caregivers, are working hard to keep the well-being of residents a priority and continue to make improvements in the care processes.”

Read the full 60-page report here.

Samaritan Bethany Home on Eighth

Samaritan Bethany Tuesday, May 4, 2021, in Rochester. (Joe Ahlquist / jahlquist@postbulletin.com)

Samaritan Bethany Tuesday, May 4, 2021, in Rochester. (Joe Ahlquist / [email protected])

Overall rating: 2 stars

Health inspections: 1 star

Staffing: 5 stars

Quality of resident care: 4 stars

Most recent report completed April 2019.

Issues identified: Nineteen deficiencies were identified as having “minimal harm or potential for actual harm.” One was listed as detailing “actual harm” to a resident.

Included in these flagged practices were issues involving the proper grooming of residents, caring for ulcers and other wounds, providing therapeutic diets for residents who require it — such as those who present a choking hazard — implementing staff evaluation and training policies, ensuring proper hand hygiene, and adequately cleaning respiratory equipment. These fell under the “minimal harm” category.

The one deficiency flagged as presenting “actual harm” was improper monitoring of a resident following an injury sustained in a fall.

The facility developed a policy to better inform family and the resident’s physician of a change in condition, as well as ensuring these changes are noted in the resident’s records.

“We always have areas to improve on and some surveys are more challenging than others,” said Kyla Berg, the facility’s community leader. “The process can be different with every survey you have, depending on the survey team, and what they’re seeing or observing at the time, or what they’re looking for.”

“After every survey, we have to write a plan of correction, and re-educate our staff and retrain them to make sure they all understand our expectations in regards to the regulations,” said Sue Knutson, Samaritan’s mission leader, pointing out that this has happened in the two years since the latest review. “So yeah, have things changed? Absolutely. We continue to work on that.”

Read the full 54-page report here.

Rochester East Health Services

Rochester East Health Services Tuesday, May 4, 2021, in Rochester. (Joe Ahlquist / jahlquist@postbulletin.com)

Rochester East Health Services Tuesday, May 4, 2021, in Rochester. (Joe Ahlquist / [email protected])

Overall rating: 2 stars

Health inspections: 1 star

Staffing: 4 stars

Quality of resident care: 4 stars

Most recent report completed August 2019.

Issues identified: Rochester East Health Services was flagged with six deficiencies that were all categorized as presenting “minimal harm or potential for actual harm” to few residents. These related to areas such as resident grooming, caring for those with skin conditions, ulcer care and prevention and ensuring equipment is sterile. The survey also identified the need to refine infection control procedures.

Read the full 10-page report here.

Edenbrook of Rochester

Edenbrook Rochester Tuesday, May 4, 2021, in Rochester. (Joe Ahlquist / jahlquist@postbulletin.com)

Edenbrook Rochester Tuesday, May 4, 2021, in Rochester. (Joe Ahlquist / [email protected])

Overall rating: 2 stars

Health inspections: 1 star

Staffing: 4 stars

Quality of resident care: 4 stars

Most recent inspection completed January 2020.

Issues identified:

Edenbrook was flagged with 17 deficiencies. Most were categorized as presenting minimal harm or potential harm for few residents.

These areas of improvement included pharmaceutical care, preventing resident accidents, tending to ulcers and wounds, communicating effectively at the time of discharge and providing safe dialysis to those in need.

One deficiency was listed as presenting immediate jeopardy to the health or safety for many residents: the lack of an appropriate infection prevention and control program.

“Edenbrook of Rochester is committed to excellence in quality of care and Resident satisfaction. Health survey data is just one piece of a complex overall picture of facility quality status and information,” said administrator Angela Lako-Quinn in a statement. “We are proud to report that our CMS 5 star ratings for both quality measures and staffing are four star rated. We are dedicated to quality assurance and improvements and are confident that new additions to our leadership team will continue to build on quality care in 2021 and beyond. “

Read the full 47-page report here.

Rochester West Health Services

Rochester West Health Services Tuesday, May 4, 2021, in Rochester. (Joe Ahlquist / jahlquist@postbulletin.com)

Rochester West Health Services Tuesday, May 4, 2021, in Rochester. (Joe Ahlquist / [email protected])

Overall rating: 3 stars

Health inspection: 2 stars

Staffing: 4 stars

Quality of resident care: 3 stars

Most recent survey completed January 2020.

Issues identified:

Rochester West Health Services was flagged with 11 deficiencies. All were classified as presenting “minimal harm or potential for actual harm” to residents.

The areas of improvement included better communication with residents’ families and doctors, improving systems to train staff and evaluate their performance, enhancing ulcer care, dental care and providing improved screening for mental disorders and intellectual disabilities.

“We also believe in continuous improvement; it’s in our core values as an organization. As is our practice following any visit from the State, we developed a plan of correction to address any identified issues and submitted it to the State of Minnesota,” wrote Kristin Mueller, senior director for of communications for North Shore Healthcare. “The efforts made by the passionate members of our divisional and center team have been represented by the recent increase in our star rating.”

The most recent star ratings are reflected above.

Read the full 20-page report here.

Rochester Rehabilitation and Living Center

Rochester Rehabilitation and Living Center on the campus of The Homestead at Rochester Tuesday, May 4, 2021, in Rochester. (Joe Ahlquist / jahlquist@postbulletin.com)

Rochester Rehabilitation and Living Center on the campus of The Homestead at Rochester Tuesday, May 4, 2021, in Rochester. (Joe Ahlquist / [email protected])

Overall rating: 3 stars

Health inspection: 2 stars

Staffing: 5 stars

Quality of resident care: 4 stars

Most recent inspection completed May 2019.

The risk ratings of the 16 deficiencies identified in the review of Rochester Rehabilitation and Living Center broke down as either minimal or potential for minimal harm. They included improving policies for reporting abuse, ensuring residents are bathed consistently, notifying residents of how long their beds will be held if they must leave the facility, and implementing gradual reductions of medication doses when possible.

Administrators from Rochester Rehabilitation and Living Center did not respond to requests for comment.

Read the full 30-page report here.

Charter House

Charter House Mayo Clinic Retirement Living Tuesday, May 4, 2021, in Rochester. (Joe Ahlquist / jahlquist@postbulletin.com)

Charter House Mayo Clinic Retirement Living Tuesday, May 4, 2021, in Rochester. (Joe Ahlquist / [email protected])

Overall rating: 5 stars

Health inspections: 4 stars

Staffing: 5 stars

Quality of Resident Care: 4 stars

Most recent inspection completed December 2019.

Issues identified:

The report listed four deficiencies, which all were flagged as having “minimal harm or potential for actual harm,” regarding the proper storage of drugs and biologics, issuance of antibiotics, efficacy of the infection control program, and ensuring pneumonia and flu vaccinations are available for all residents.

Laura Swenson, director of health services at Charter House, said the facility’s strong training guidelines and regular training updates contribute to its success. They are also aided by having a registered nurse on staff 24 hours a day, even in the assisted living unit.

“When you have a passion for what you do — for taking care of our seniors — despite the hard work, it’s easy work in some regard,” Swenson said. “You just come together as a family.”

Read the full 5-page report here.