Minnesota ›Elk River

Guardian Angels Care Center

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400 Evans Avenue, Elk River, MN 55330 (opens Google Maps) · Sherburne County · (763) 635-5475· 120 certified beds · avg 101 residents/day · certified since Jan 1, 1967 · Medicare and Medicaid certified

Certified for both programmes. Certification means the facility can bill Medicaid — it does not mean a Medicaid-funded bed is free right now, so ask directly. Who pays for nursing home care →

2/5
Health inspection rating (on-site)
inspected Dec 10, 2025
4
Serious findings on record
most recent Jan 24, 2025
$98,353
Fines, last 3 years
4.98
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

New to these records? How to read an inspection report →

Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5 · how star ratings work →

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 quality measures from resident assessments and claims.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, widespread · Jan 24, 2025 · F-0880

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.

Why it matters: Weak infection control lets illnesses like flu, COVID-19, and drug-resistant infections spread quickly among vulnerable residents.

Severity (L): Immediate jeopardy to resident health or safety was cited. The scope was widespread: a systemic or pervasive problem. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Mar 24, 2025 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, isolated · Jul 17, 2024 · F-0806 · triggered by a complaint

The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives.

Why it matters: Ignoring allergies can be dangerous, and ignoring preferences leads residents to eat less and lose weight.

Severity (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Jul 11, 2024 (Past Non-Compliance)

▲ Immediate jeopardy, isolated · May 16, 2024 · 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 (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Jun 7, 2024 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, isolated · Apr 11, 2024 · F-0578

The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.

Why it matters: Ignoring these rights means residents may receive treatments they refused, or miss having their end-of-life wishes respected.

Severity (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Apr 29, 2024 (Deficient, Provider has date of correction)

Inspection findings in the public record

Showing the latest 3 of 18 inspection findings. Open the full record below to read every finding.

  1. D · Potential for more than minimal harm, isolated

    The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint F-0690

  2. D · Potential for more than minimal harm, isolated

    The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint F-0550

  3. D · Potential for more than minimal harm, isolated

    The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint F-0695

View all 18 inspection findingsShow only the latest 3 findings

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.

DateSeverityWhat the facility was cited for
Mar 19, 2026D · Potential for more than minimal harm, isolatedThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint · F-0690
Sep 9, 2025D · Potential for more than minimal harm, isolatedThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint · F-0550
Apr 24, 2025D · Potential for more than minimal harm, isolatedThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint · F-0695
Jan 24, 2025▲ L · Immediate jeopardy, widespreadThe 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. · F-0880
Jan 24, 2025F · Potential for more than minimal harm, widespreadThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812
Jan 24, 2025E · Potential for more than minimal harm, patternThe 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. · F-0677
Jan 24, 2025E · Potential for more than minimal harm, patternThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · F-0804
Jan 24, 2025D · Potential for more than minimal harm, isolatedThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · F-0550
Jan 24, 2025D · Potential for more than minimal harm, isolatedThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · F-0641
Jan 24, 2025D · Potential for more than minimal harm, isolatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · F-0684
Sep 12, 2024D · Potential for more than minimal harm, isolatedThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint · F-0558
Jul 17, 2024▲ J · Immediate jeopardy, isolatedThe facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · from a complaint · F-0806
May 16, 2024▲ J · Immediate jeopardy, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Apr 11, 2024▲ J · Immediate jeopardy, isolatedThe facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. · F-0578
Apr 11, 2024D · Potential for more than minimal harm, isolatedThe facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. · F-0554
Apr 11, 2024D · Potential for more than minimal harm, isolatedThe 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. · F-0688
Apr 11, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · F-0698
Mar 14, 2024D · Potential for more than minimal harm, isolatedThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint · F-0610

Inspection trend by year

Citations by recorded inspection yearPublished citation counts, not a quality score · Source: CMS, 2026-08-01
All citationsSerious citations (G–L)
2024
All citations: 8
Serious citations (G–L): 3
2025
All citations: 9
Serious citations (G–L): 1
2026
All citations: 1
Serious citations (G–L): 0

All bars start at zero. Exact values and supporting details remain below.

YearCitationsSerious (G–L)Worst severity that year
202483J ▲
202591L ▲
202610D

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)

How to file a complaint about care →

4 fines totaling $98,353, plus 1 Medicare payment denial period.

Every penalty CMS publishes for this facility in the 3-year window is listed —none excluded. The count and the dollar total come from two different CMS datasets and agree for this facility. Penalties older than the window are dropped by CMS before publication, not by us.

DateTypeAmount / length
Jan 24, 2025Fine$59,010
Jan 24, 2025Payment Denial26 days from Feb 26, 2025
Jul 17, 2024Fine$13,627
May 16, 2024Fine$16,801
Mar 14, 2024Fine$8,915

Nurse staffing (from payroll records, adjusted for how much care residents need)

What these staffing numbers mean →

Nurse time, in contextAdjusted hours per resident per day · Source: CMS, 2026-08-01
This facilityMinnesota averageU.S. average
Total nurse staffing (hours per resident per day)
This facility: 4.98
Minnesota average: 4.83
U.S. average: 3.95
Registered Nurse hours
This facility: 1.55
Minnesota average: 1.22
U.S. average: 0.69
Weekend total nurse staffing
This facility: 4.46
Minnesota average: 4.27
U.S. average: 3.50

All bars start at zero. Exact values and supporting details remain below.

MeasureThis facilityMinnesota avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)4.984.833.95top 40% in Minnesota; top 13% in the U.S.
Registered Nurse hours1.551.220.69top 18% in Minnesota; top 4% in the U.S.
Weekend total nurse staffing4.464.273.50top 38% in Minnesota; top 13% in the U.S.
Weekend RN hours (not acuity-adjusted)0.900.690.48top 21% in Minnesota; top 8% in the U.S.
Total nursing staff turnover (%)51.042.245.8bottom 25% in Minnesota; bottom 34% in the U.S.
RN turnover (%)51.238.642.9bottom 23% in Minnesota; bottom 32% in the U.S.

Hours are per resident per day for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — 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 4.81, RN 1.49, weekend 4.31.Comparing with Medicare Care Compare? Care Compare shows the raw figure (4.81 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 4/5.

Quality measures: assessments & claims

Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.

Quality measures rating: 3/5 · long-stay residents: 4/5 · short-stay residents: 2/5

Costs & payment

Price evidence · separate from quality

No verified facility-specific private-pay price is available in our data for Guardian Angels Care Center. CMS inspection and staffing records do not tell us what this home will charge you.

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Understand who pays for care · How we handle price evidence · Report an incorrect price

Who owns this facility

How to read ownership records →

Ownership records as published by CMS on 2026-08-01. CMS records when an owner joined but not when they left. Listed here and no longer involved? Tell us →

Non profit - Corporation

Owner / managerTypeRoleStakeSince
Guardian Angels Health Services, INC.OrganizationOperational/Managerial ControlNOT APPLICABLE01/01/1967
Heinecke, CarlieIndividualW-2 Managing EmployeeNOT APPLICABLE05/06/2024
Heinecke, CarlieIndividualADP of the SNFNOT APPLICABLE12/27/2024
Herrmann, DarylIndividualCorporate OfficerNOT APPLICABLE01/01/2018
Krieger, LindaIndividualCorporate OfficerNOT APPLICABLE04/15/2010
Larson, TraciIndividualW-2 Managing EmployeeNOT APPLICABLE05/02/2022
Larson, TraciIndividualCorporate OfficerNOT APPLICABLE05/02/2022
Larson, TraciIndividualOperational/Managerial ControlNOT APPLICABLE05/02/2022
Leclaire, JoyceIndividualCorporate DirectorNOT APPLICABLE01/01/2019
Lloyd Roscoe, NancyIndividualCorporate DirectorNOT APPLICABLE01/01/2018
McDevitt, DeanIndividualW-2 Managing EmployeeNOT APPLICABLE02/04/2019
Mowry, TrishaIndividualCorporate DirectorNOT APPLICABLE01/01/2021
Nagorski, JeffIndividualCorporate DirectorNOT APPLICABLE01/01/2014
Nichols, JoanieIndividualCorporate DirectorNOT APPLICABLE01/01/2016
Raitz, JulieIndividualCorporate DirectorNOT APPLICABLE01/01/2017
Robinson, ChrisIndividualCorporate DirectorNOT APPLICABLE01/01/2017
Schuler, LynnIndividualCorporate DirectorNOT APPLICABLE01/01/2018
Schultz, ArloIndividualCorporate DirectorNOT APPLICABLE01/01/2015
Sonntag, RobertIndividualContracted Managing EmployeeNOT APPLICABLE03/15/2006
Vetsch, GordyIndividualCorporate DirectorNOT APPLICABLE01/01/2018

Showing 20 of 21 parties CMS has on file for this facility; 1 are not displayed. The full list is in the CMS Ownership dataset.

Questions to ask on your visit

Full visit checklist →

Print visit checklist

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

  • "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
  • "How do you track each resident's food allergies and preferences, and what happens if they don't like what's served?"
  • "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
  • "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
  • "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
  • "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
  • "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
  • "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"

Also worth asking anywhere

  • "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
  • "Can I see the plan of correction for the findings in your most recent state inspection?"
  • "CMS reports 51% total nursing staff turnover here — who on the care team has been with you longest?"
  • "The ownership record on file lists 21 owning or managing parties — who makes the decisions about staffing levels?"
  • "Can I visit again unannounced, at a mealtime or on a weekend?"

Nearby facilities (12 closest of 13 within 20 miles)

FacilityDistanceCityOverallInspectionFlags
Cura of Monticello10.7 miMonticello, MN★★☆☆☆3/5
Anoka Rehabilitation and Living Center10.8 miAnoka, MN★★★★☆3/5
The Estates at Twin Rivers LLC10.9 miAnoka, MN★★☆☆☆2/5
The Villas at Osseo LLC15.4 miOsseo, MN★☆☆☆☆1/5abuse
Park River Healthcare and Rehabilitation Center LL16.6 miCoon Rapids, MN★★☆☆☆1/5
Saint Therese at Oxbow Lake17.0 miBrooklyn Park, MN★★★☆☆2/5
The Birches at Trillium Woods17.5 miPlymouth, MN★★★★★4/5
Park View Health Care Center18.0 miBuffalo, MN★★★★★5/5
Lake Ridge Care Center of Buffalo, INC.18.1 miBuffalo, MN★★★★☆4/5
Elim Wellspring Health Care Center18.3 miPrinceton, MN★★★★★5/5
Maranatha Care Center18.7 miBrooklyn Center, MN★★★★☆4/5
Woodlake Healthcare and Rehabilitation Center19.3 miCrystal, MN★★★☆☆3/5

Compare this facility with the 3 closest →

Other facilities in the same county

CMS records place this facility in Sherburne, MN — 2 certified facilities there. These are outside the 20-mile list above, or far enough down it not to appear.

Listed by facility name — not a ranking. Homes already in the table above are not repeated here.

All facilities in Elk River →

Facility data as of CMS processing date 2026-08-01. CCN 245012.

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