Madison Healthcare Services
900 Second Avenue, Madison, MN 56256 · Lac Qui Parle County · 51 certified beds · avg 46 residents/day · certified since Dec 1, 1986
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · CMS overall rating: 4/5
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 · Feb 28, 2024 · F-0689
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: Mar 8, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (16)
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 |
|---|---|---|
| Jan 27, 2026 | 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. |
| Jan 27, 2026 | 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. |
| Jan 27, 2026 | 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 16, 2026 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Jan 16, 2026 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint |
| Jun 4, 2025 | 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 |
| Jun 4, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Jun 4, 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. · from a complaint |
| Nov 6, 2024 | E · Potential for harm, repeated | The facility did not provide its staff with required training on behavioral health — caring for residents with conditions like dementia, depression, or other mental health needs. |
| Nov 6, 2024 | D · Potential for harm, one-off | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. |
| Nov 6, 2024 | D · Potential for 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. |
| Feb 28, 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. |
| Feb 28, 2024 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Feb 28, 2024 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Feb 28, 2024 | D · Potential for harm, one-off | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. |
| Nov 17, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
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 | 1 | 0 | D |
| 2024 | 7 | 1 | J ▲ |
| 2025 | 3 | 0 | D |
| 2026 | 5 | 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)
1 fine totaling $10,036.
| Date | Type | Amount / length |
|---|---|---|
| Feb 28, 2024 | Fine | $10,036 |
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) | 5.68 | 4.83 | 3.95 | top 14% in Minnesota; top 6% in the U.S. |
| Registered Nurse hours | 0.93 | 1.22 | 0.69 | bottom 26% in Minnesota; top 19% in the U.S. |
| Weekend total nurse staffing | 4.97 | 4.27 | 3.50 | top 16% in Minnesota; top 7% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.32 | 0.69 | 0.48 | bottom 9% in Minnesota; bottom 37% in the U.S. |
| Total nursing staff turnover (%) | 100.0 | 42.2 | 45.8 | bottom 1% in Minnesota; bottom 1% in the U.S. |
| RN turnover (%) | 100.0 | 38.6 | 42.9 | bottom 2% in Minnesota; bottom 1% 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 4.22, RN 0.69, weekend 3.69. Staffing rating: 3/5.
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: 3/5 · short-stay residents: —/5
Who owns this facility
Non profit - Church related
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Bjerke, Erik | Individual | W-2 Managing Employee | NOT APPLICABLE | 09/25/2015 |
| Bjerke, Erik | Individual | ADP of the SNF | NOT APPLICABLE | 01/16/2025 |
| Borgerson, Carol | Individual | Corporate Officer | NOT APPLICABLE | 11/04/2014 |
| Engebretson, Ramona | Individual | W-2 Managing Employee | NOT APPLICABLE | 12/14/2018 |
| Hacker, Brant | Individual | W-2 Managing Employee | NOT APPLICABLE | 09/19/2005 |
| Hastad, Trudy | Individual | Corporate Director | NOT APPLICABLE | 01/01/2024 |
| Hill, Bart | Individual | Corporate Director | NOT APPLICABLE | 01/01/2024 |
| Moen, Karin | Individual | Corporate Director | NOT APPLICABLE | 01/01/2019 |
| Munsterman, Jeanene | Individual | Corporate Director | NOT APPLICABLE | 01/01/2024 |
| Omland, Scott | Individual | Corporate Director | NOT APPLICABLE | 01/01/2023 |
| Volk, Tim | Individual | Corporate Director | NOT APPLICABLE | 01/01/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "If my family member is able to manage their own medications, would you allow it, and how is that decided?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "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 |
|---|---|---|---|---|---|
| Johnson Memorial Hospital & Home | 8.4 mi | Dawson, MN | ★★★☆☆ | 4/5 | |
| Appleton Area Health | 15.3 mi | Appleton, MN | ★★★☆☆ | 4/5 |
Compare this facility with the 2 closest →
Facility data as of CMS processing date 2026-08-01. CCN 245382.