Avera Granite Falls Care Center
250 Jordan Drive, Granite Falls, MN 56241 · Yellow Medcine County · 48 certified beds · avg 46 residents/day · certified since Jul 6, 1981
Part of chain: AVERA HEALTH (13 facilities, chain avg rating 3.7★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · May 2, 2024 · F-0678 · triggered by a complaint
The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes.
Why it matters: In a cardiac or breathing emergency, failure to start CPR promptly can be the difference between life and death.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Apr 30, 2024 (Past Non-Compliance)
▲ Actual harm, one-off · Sep 19, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 12, 2025 (Past Non-Compliance)
All citations in the current public record (17)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Sep 19, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 10, 2025 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 10, 2025 | F · Potential for harm, facility-wide | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. |
| Sep 10, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Sep 10, 2025 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Jul 17, 2024 | F · Potential for harm, facility-wide | The facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately. |
| Jul 17, 2024 | E · Potential for harm, repeated | The facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. |
| Jul 17, 2024 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. |
| Jul 17, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jul 17, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jul 17, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| May 2, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. · from a complaint |
| Feb 29, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Feb 29, 2024 | D · Potential for harm, one-off | The facility did not provide or obtain laboratory tests when a doctor ordered them, or did not promptly report the results back to the doctor who ordered them. · from a complaint |
| Aug 10, 2023 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Aug 10, 2023 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Aug 10, 2023 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (6 → 4).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 3 | 0 | E |
| 2024 | 9 | 1 | J ▲ |
| 2025 | 5 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $15,642.
| Date | Type | Amount / length |
|---|---|---|
| May 2, 2024 | Fine | $15,642 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Minnesota avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.42 | 4.83 | 3.95 | top 20% in Minnesota; top 8% in the U.S. |
| Registered Nurse hours | 1.17 | 1.22 | 0.69 | top 46% in Minnesota; top 10% in the U.S. |
| Weekend total nurse staffing | 4.87 | 4.27 | 3.50 | top 20% in Minnesota; top 8% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.52 | 0.69 | 0.48 | bottom 39% in Minnesota; top 30% in the U.S. |
| Total nursing staff turnover (%) | 25.0 | 42.2 | 45.8 | top 11% in Minnesota; top 7% in the U.S. |
| RN turnover (%) | 25.0 | 38.6 | 42.9 | top 27% in Minnesota; top 20% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.81, RN 0.82, weekend 3.43. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: —/5
Who owns this facility
Non profit - Church related
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Avera Health | Organization | Indirect Ownership Interest | NOT APPLICABLE | 01/01/2020 |
| Avera Marshall | Organization | 5% or Greater Direct Ownership Interest | 100% | 01/01/2020 |
| Barber, Daniel | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2024 |
| Carter, Darrell | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2020 |
| Carter, Darrell | Individual | ADP of the SNF | NOT APPLICABLE | 12/16/2025 |
| Coudron, Christy | Individual | Corporate Officer | NOT APPLICABLE | 09/01/2020 |
| Jensen, Mark | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2023 |
| Koenen, Lavonne | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2020 |
| Kooiman, Thomas | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2020 |
| Kooiman, Thomas | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2020 |
| Kooiman, Thomas | Individual | ADP of the SNF | NOT APPLICABLE | 12/16/2025 |
| Lautt, Julie | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2020 |
| Lautt, Julie | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2020 |
| Rios Avendano, Rosa | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2023 |
| Streich, Lisa | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2024 |
| Streier, Debra | Individual | Corporate Officer | NOT APPLICABLE | 02/01/2021 |
| Welbig, Lucille | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2023 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Are staff on every shift trained and certified in CPR, and how do they know each resident's resuscitation wishes?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Who is your infection preventionist, and what training do they have?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "What percentage of your residents and staff are vaccinated against flu and pneumonia, and how do you offer the vaccines?"
- "How can my family member make private phone or video calls, and can we see where?"
- "How do you train staff to treat residents with dignity, and how do you protect residents' personal belongings?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Parkview Home | 1.0 mi | Belview, MN | ★★★☆☆ | 2/5 | |
| Clara City Care Center | 12.8 mi | Clara City, MN | ★☆☆☆☆ | 1/5 | |
| Luther Haven | 13.4 mi | Montevideo, MN | ★☆☆☆☆ | 1/5 | |
| Clarkfield Care Center | 14.2 mi | Clarkfield, MN | ★★★★☆ | 4/5 | |
| Renvilla Health Center | 15.4 mi | Renville, MN | ★★★★★ | 4/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 245243.