Avera Morningside Heights Care Center
300 South Bruce Street, Marshall, MN 56258 · Lyon County · 76 certified beds · avg 72 residents/day · certified since Aug 1, 1979
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 · Sep 24, 2025 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
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: Sep 21, 2025 (Past Non-Compliance)
▲ Actual harm, one-off · Mar 24, 2026 · 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: Apr 21, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 30, 2023 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
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: Jan 4, 2024 (Deficient, Provider has date of correction)
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 |
|---|---|---|
| Mar 24, 2026 | ▲ 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 |
| Dec 3, 2025 | F · Potential for harm, facility-wide | The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. |
| Dec 3, 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. |
| Dec 3, 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 24, 2025 | ▲ J · Immediate jeopardy, 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 |
| Oct 30, 2024 | 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. |
| Oct 30, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Oct 30, 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. |
| Nov 30, 2023 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Nov 30, 2023 | F · Potential for harm, facility-wide | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Nov 30, 2023 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Nov 30, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Nov 30, 2023 | E · Potential for harm, repeated | 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. |
| Nov 30, 2023 | E · Potential for harm, repeated | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Nov 30, 2023 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Nov 30, 2023 | D · Potential for harm, 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. |
| Nov 30, 2023 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (3 → 3).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 9 | 1 | G ▲ |
| 2024 | 3 | 0 | F |
| 2025 | 4 | 1 | J ▲ |
| 2026 | 1 | 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 $17,345, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Sep 24, 2025 | Fine | $17,345 |
| Nov 30, 2023 | Payment Denial | 6 days from Jan 4, 2024 |
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) | 5.19 | 4.83 | 3.95 | top 31% in Minnesota; top 11% in the U.S. |
| Registered Nurse hours | 1.09 | 1.22 | 0.69 | bottom 47% in Minnesota; top 12% in the U.S. |
| Weekend total nurse staffing | 4.83 | 4.27 | 3.50 | top 21% in Minnesota; top 8% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.68 | 0.69 | 0.48 | top 40% in Minnesota; top 17% in the U.S. |
| Total nursing staff turnover (%) | 24.4 | 42.2 | 45.8 | top 10% in Minnesota; top 6% in the U.S. |
| RN turnover (%) | 33.3 | 38.6 | 42.9 | top 45% in Minnesota; top 33% 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 4.80, RN 1.01, weekend 4.46. 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: 3/5 · long-stay residents: 2/5 · short-stay residents: 5/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Avera Health | Organization | 5% or Greater Direct Ownership Interest | 100% | 11/01/2009 |
| Coudron, Christy | Individual | Corporate Officer | NOT APPLICABLE | 09/01/2020 |
| Deutz, Tracy | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/14/2024 |
| Deutz, Tracy | Individual | ADP of the SNF | NOT APPLICABLE | 12/16/2025 |
| Hennen, Sharon | Individual | Corporate Director | NOT APPLICABLE | 07/01/2023 |
| Koenen, Lavonne | Individual | Corporate Director | NOT APPLICABLE | 07/01/2020 |
| Lautt, Julie | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2020 |
| Lorang, Thomas | Individual | Corporate Director | NOT APPLICABLE | 07/01/2024 |
| Louwagie, Curtis | Individual | Corporate Director | NOT APPLICABLE | 07/01/2018 |
| Novak, Karie | Individual | Corporate Director | NOT APPLICABLE | 07/01/2024 |
| O'Leary, Tim | Individual | Corporate Director | NOT APPLICABLE | 07/01/2023 |
| Sieling, Amanda | Individual | Corporate Director | NOT APPLICABLE | 07/01/2018 |
| Streier, Debra | Individual | Corporate Officer | NOT APPLICABLE | 02/01/2021 |
| Vroman, Jill | Individual | Corporate Director | NOT APPLICABLE | 07/01/2023 |
| Walker, Victoria | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/01/2020 |
| Walker, Victoria | Individual | ADP of the SNF | NOT APPLICABLE | 02/09/2026 |
| Zimmerman, Jodelle | Individual | Corporate Director | NOT APPLICABLE | 07/01/2018 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "How does your quality committee work, and can you share an example of a problem it identified and fixed?"
- "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?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "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 |
|---|---|---|---|---|---|
| Prairie View Senior Living | 17.1 mi | Tracy, MN | ★★★☆☆ | 3/5 |
Compare this facility with the 1 closest →
Facility data as of CMS processing date 2026-08-01. CCN 245228.