Guardian Angels Care Center
400 Evans Avenue, Elk River, MN 55330 · Sherburne County · 120 certified beds · avg 101 residents/day · certified since Jan 1, 1967
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
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, facility-wide · 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): A life-threatening or extremely dangerous situation existed throughout the facility. The single most serious citation CMS can issue.
Corrected: Mar 24, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · 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): 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: Jul 11, 2024 (Past Non-Compliance)
▲ Immediate jeopardy, one-off · 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): 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: Jun 7, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · 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): 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 29, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (18)
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 19, 2026 | D · Potential for harm, one-off | 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 |
| Sep 9, 2025 | D · Potential for harm, one-off | 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 |
| Apr 24, 2025 | D · Potential for harm, one-off | 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 |
| Jan 24, 2025 | ▲ L · Immediate jeopardy, 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. |
| Jan 24, 2025 | F · Potential for harm, facility-wide | 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. |
| Jan 24, 2025 | E · Potential for harm, repeated | 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. |
| Jan 24, 2025 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Jan 24, 2025 | D · Potential for harm, one-off | 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. |
| Jan 24, 2025 | 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. |
| Jan 24, 2025 | 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. |
| Sep 12, 2024 | D · Potential for harm, one-off | The 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 |
| Jul 17, 2024 | ▲ J · Immediate jeopardy, one-off | The 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 |
| May 16, 2024 | ▲ J · Immediate jeopardy, 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 |
| Apr 11, 2024 | ▲ J · Immediate jeopardy, one-off | 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. |
| Apr 11, 2024 | D · Potential for harm, one-off | The 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. |
| Apr 11, 2024 | 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. |
| Apr 11, 2024 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Mar 14, 2024 | D · Potential for harm, one-off | The 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 |
Inspection trend by year
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 8 | 3 | J ▲ |
| 2025 | 9 | 1 | L ▲ |
| 2026 | 1 | 0 | D |
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)
4 fines totaling $98,353, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Jan 24, 2025 | Fine | $59,010 |
| Jan 24, 2025 | Payment Denial | 26 days from Feb 26, 2025 |
| Jul 17, 2024 | Fine | $13,627 |
| May 16, 2024 | Fine | $16,801 |
| Mar 14, 2024 | Fine | $8,915 |
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) | 4.98 | 4.83 | 3.95 | top 40% in Minnesota; top 13% in the U.S. |
| Registered Nurse hours | 1.55 | 1.22 | 0.69 | top 18% in Minnesota; top 4% in the U.S. |
| Weekend total nurse staffing | 4.46 | 4.27 | 3.50 | top 38% in Minnesota; top 13% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.90 | 0.69 | 0.48 | top 21% in Minnesota; top 8% in the U.S. |
| Total nursing staff turnover (%) | 51.0 | 42.2 | 45.8 | bottom 25% in Minnesota; bottom 34% in the U.S. |
| RN turnover (%) | 51.2 | 38.6 | 42.9 | bottom 23% in Minnesota; bottom 32% 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 4.81, RN 1.49, weekend 4.31. Staffing rating: 4/5.
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: 4/5 · short-stay residents: 2/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Guardian Angels Health Services, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/1967 |
| Heinecke, Carlie | Individual | W-2 Managing Employee | NOT APPLICABLE | 05/06/2024 |
| Heinecke, Carlie | Individual | ADP of the SNF | NOT APPLICABLE | 12/27/2024 |
| Herrmann, Daryl | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2018 |
| Krieger, Linda | Individual | Corporate Officer | NOT APPLICABLE | 04/15/2010 |
| Larson, Traci | Individual | W-2 Managing Employee | NOT APPLICABLE | 05/02/2022 |
| Larson, Traci | Individual | Corporate Officer | NOT APPLICABLE | 05/02/2022 |
| Larson, Traci | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/02/2022 |
| Leclaire, Joyce | Individual | Corporate Director | NOT APPLICABLE | 01/01/2019 |
| Lloyd Roscoe, Nancy | Individual | Corporate Director | NOT APPLICABLE | 01/01/2018 |
| McDevitt, Dean | Individual | W-2 Managing Employee | NOT APPLICABLE | 02/04/2019 |
| Mowry, Trisha | Individual | Corporate Director | NOT APPLICABLE | 01/01/2021 |
| Nagorski, Jeff | Individual | Corporate Director | NOT APPLICABLE | 01/01/2014 |
| Nichols, Joanie | Individual | Corporate Director | NOT APPLICABLE | 01/01/2016 |
| Raitz, Julie | Individual | Corporate Director | NOT APPLICABLE | 01/01/2017 |
| Robinson, Chris | Individual | Corporate Director | NOT APPLICABLE | 01/01/2017 |
| Schuler, Lynn | Individual | Corporate Director | NOT APPLICABLE | 01/01/2018 |
| Schultz, Arlo | Individual | Corporate Director | NOT APPLICABLE | 01/01/2015 |
| Sonntag, Robert | Individual | Contracted Managing Employee | NOT APPLICABLE | 03/15/2006 |
| Vetsch, Gordy | Individual | Corporate Director | NOT APPLICABLE | 01/01/2018 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "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?"
- "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 |
|---|---|---|---|---|---|
| Cura of Monticello | 10.7 mi | Monticello, MN | ★★☆☆☆ | 3/5 | |
| Anoka Rehabilitation and Living Center | 10.8 mi | Anoka, MN | ★★★★☆ | 3/5 | |
| The Estates at Twin Rivers LLC | 10.9 mi | Anoka, MN | ★★☆☆☆ | 2/5 | |
| The Villas at Osseo LLC | 15.4 mi | Osseo, MN | ★☆☆☆☆ | 1/5 | abuse |
| Park River Healthcare and Rehabilitation Center LL | 16.6 mi | Coon Rapids, MN | ★★☆☆☆ | 1/5 | |
| Saint Therese at Oxbow Lake | 17.0 mi | Brooklyn Park, MN | ★★★☆☆ | 2/5 | |
| The Birches at Trillium Woods | 17.5 mi | Plymouth, MN | ★★★★★ | 4/5 | |
| Park View Health Care Center | 18.0 mi | Buffalo, MN | ★★★★★ | 5/5 | |
| Lake Ridge Care Center of Buffalo, INC. | 18.1 mi | Buffalo, MN | ★★★★☆ | 4/5 | |
| Elim Wellspring Health Care Center | 18.3 mi | Princeton, MN | ★★★★★ | 5/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 245012.