Stewartville Care Center

Name: Stewartville Care Center
Address: 120 FOURTH STREET NORTHEAST, Stewartville, MN, 55976, US
Telephone: 5075334288

120 Fourth Street Northeast, Stewartville, MN 55976 · Olmsted County · 50 certified beds · avg 43 residents/day · certified since Sep 1, 1986

Abuse citation flag (CMS)

The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.

2/5

Health inspection rating (on-site)

Serious findings on record

$11,911

Fines, last 3 years

5.24

Nurse hours/resident/day (adjusted)

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

Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 1/5

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)

▲ Actual harm, one-off · Apr 7, 2026 · F-0600 · triggered by a complaint

The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.

Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.

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: May 1, 2026 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Jun 12, 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 (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Jul 3, 2024 (Deficient, Provider has date of correction)

All citations in the current public record (30)

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
Jun 18, 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.
Jun 18, 2026	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.
Jun 18, 2026	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.
Jun 18, 2026	D · Potential for harm, one-off	The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have.
Jun 18, 2026	D · Potential for 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.
Jun 18, 2026	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.
Apr 7, 2026	▲ G · Actual harm, one-off	The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Dec 4, 2025	D · Potential for harm, one-off	The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. · from a complaint
Apr 3, 2025	E · Potential for harm, repeated	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.
Apr 3, 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.
Apr 3, 2025	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.
Apr 3, 2025	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.
Apr 3, 2025	E · Potential for harm, repeated	The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices.
Apr 3, 2025	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.
Dec 12, 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. · from a complaint
Jun 12, 2024	▲ 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
Jun 12, 2024	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Jun 12, 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
Jun 12, 2024	D · Potential for harm, one-off	The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. · from a complaint
May 24, 2024	F · Potential for harm, facility-wide	The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. · from a complaint
May 24, 2024	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. · from a complaint
May 24, 2024	D · Potential for harm, one-off	The facility did not make sure special medical diets — like low-sodium or diabetic diets — were properly ordered by the resident's doctor or managed by a qualified dietitian as state law allows. · from a complaint
Jan 11, 2024	E · Potential for harm, repeated	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Jan 11, 2024	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. · from a complaint
Jan 11, 2024	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
Jan 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.
Jan 11, 2024	D · Potential for harm, one-off	The facility did not keep residents' personal and medical information private and confidential.
Jan 11, 2024	D · Potential for harm, one-off	The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint
Jan 11, 2024	D · Potential for harm, one-off	The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Jan 11, 2024	D · Potential for harm, one-off	The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (6 → 6).

Year	Citations	Serious (G–L)	Worst severity that year
2024	16	1	G ▲
2025	7	0	E
2026	7	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 $11,911.

Date	Type	Amount / length
Sep 1, 2023	Fine	$11,911

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)	5.24	4.83	3.95	top 26% in Minnesota; top 10% in the U.S.
Registered Nurse hours	1.07	1.22	0.69	bottom 44% in Minnesota; top 13% in the U.S.
Weekend total nurse staffing	4.54	4.27	3.50	top 33% in Minnesota; top 11% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.39	0.69	0.48	bottom 18% in Minnesota; top 49% in the U.S.
Total nursing staff turnover (%)	60.3	42.2	45.8	bottom 12% in Minnesota; bottom 16% in the U.S.
RN turnover (%)	50.0	38.6	42.9	bottom 32% in Minnesota; bottom 39% 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 4.36, RN 0.89, weekend 3.78. 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: 1/5 · long-stay residents: 1/5 · short-stay residents: 3/5

Who owns this facility

Non profit - Corporation

Owner / manager	Type	Role	Stake	Since
City of Stewartville	Organization	ADP of the SNF	NOT APPLICABLE	10/20/1969
Evans, Jackie	Individual	Corporate Director	NOT APPLICABLE	03/01/2023
Feijo, Laurie	Individual	Operational/Managerial Control	NOT APPLICABLE	08/09/2024
Feijo, Laurie	Individual	ADP of the SNF	NOT APPLICABLE	08/09/2024
Grisim, Connie	Individual	Corporate Director	NOT APPLICABLE	09/01/1986
Hoesing, Amanda	Individual	Operational/Managerial Control	NOT APPLICABLE	06/13/2011
Hoesing, Amanda	Individual	ADP of the SNF	NOT APPLICABLE	06/13/2011
Honsey, Daniel	Individual	Corporate Director	NOT APPLICABLE	09/27/2023
Jones, Jarett	Individual	Corporate Director	NOT APPLICABLE	03/01/2016
Lammers, Lauren	Individual	Operational/Managerial Control	NOT APPLICABLE	05/06/2019
Lammers, Lauren	Individual	ADP of the SNF	NOT APPLICABLE	05/06/2019
Lassig, Sara	Individual	Corporate Director	NOT APPLICABLE	03/01/2024
Nelson, Margaret	Individual	Corporate Director	NOT APPLICABLE	09/01/1986
Neuzil, Carol	Individual	Operational/Managerial Control	NOT APPLICABLE	01/29/2007
Neuzil, Carol	Individual	ADP of the SNF	NOT APPLICABLE	01/29/2007
Nogosek, Jennifer	Individual	Corporate Director	NOT APPLICABLE	04/01/2023
Nogosek, Jennifer	Individual	Operational/Managerial Control	NOT APPLICABLE	04/01/2023
Nogosek, Jennifer	Individual	ADP of the SNF	NOT APPLICABLE	08/17/2020
Swanton, Kristin	Individual	Operational/Managerial Control	NOT APPLICABLE	01/23/2012
Swanton, Kristin	Individual	ADP of the SNF	NOT APPLICABLE	01/23/2012

Questions to ask on your visit

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

"Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
"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?"
"Before any service that isn't covered by Medicare or Medicaid, how will you notify us and get our agreement?"
"Can you show me an example care plan, and how are families included when it's created and updated?"
"How do you help residents maintain their daily living skills, and how do you measure whether it's working?"
"How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
"How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
"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
Rochester Restorative Care Center	11.2 mi	Rochester, MN	★☆☆☆☆	1/5
Meadow Manor	11.3 mi	Grand Meadow, MN	★★★☆☆	4/5
Charter House INC	11.6 mi	Rochester, MN	★★★★★	4/5
Spring Valley Care Center	12.1 mi	Spring Valley, MN	★★★☆☆	3/5
Samaritan Bethany Home on Eighth	12.1 mi	Rochester, MN	★★★☆☆	3/5
Edenbrook of Rochester	12.8 mi	Rochester, MN	★★☆☆☆	2/5
Edenbrook Rochester West	13.1 mi	Rochester, MN	★★☆☆☆	1/5
Madonna Towers of Rochester	14.3 mi	Rochester, MN	★★★☆☆	3/5
Rochester Rehabilitation and Living Center	15.5 mi	Rochester, MN	★☆☆☆☆	1/5
Chosen Valley Care Center	15.5 mi	Chatfield, MN	★★★★★	5/5
Ostrander Care and Rehab	17.1 mi	Ostrander, MN	★★★★★	5/5
Field Crest Care Center	17.9 mi	Hayfield, MN	★★★★★	5/5

Compare this facility with the 3 closest →

All facilities in Stewartville →

Facility data as of CMS processing date 2026-08-01. CCN 245349.

The Care File

Visit checklist — Stewartville Care Center

120 Fourth Street Northeast, Stewartville, MN 55976 · 5075334288

Health inspection rating 2/5 · CMS overall 1/5 · ▲ FEDERAL ABUSE CITATION FLAG· Fines (3y): $11,911

Most serious findings on record:

▲ Apr 7, 2026 (F-0600, Actual harm, one-off): The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
▲ Jun 12, 2024 (F-0689, 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.

Questions for the administrator:

☐ "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
☐ "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?"
☐ "Before any service that isn't covered by Medicare or Medicaid, how will you notify us and get our agreement?"
☐ "Can you show me an example care plan, and how are families included when it's created and updated?"
☐ "How do you help residents maintain their daily living skills, and how do you measure whether it's working?"
☐ "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
☐ "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
☐ "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?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 245349 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)