Zumbrota Care Center
433 Mill Street, Zumbrota, MN 55992 · Goodhue County · 42 certified beds · avg 34 residents/day · certified since Dec 1, 1986
Part of chain: ST. FRANCIS HEALTH SERVICES (14 facilities, chain avg rating 2.8★)
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 · May 27, 2025 · 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 30, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (24)
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 |
|---|---|---|
| Dec 2, 2025 | 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. · from a complaint |
| Nov 26, 2025 | 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. · from a complaint |
| Nov 26, 2025 | 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 |
| Aug 7, 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. · from a complaint |
| Aug 7, 2025 | 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. |
| Aug 7, 2025 | C · Minimal risk, facility-wide | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| May 27, 2025 | ▲ 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 |
| May 27, 2025 | F · Potential for harm, facility-wide | The facility was not properly licensed, or did not operate in compliance with federal, state, and local laws, regulations, and accepted professional standards. · from a complaint |
| May 27, 2025 | F · Potential for harm, facility-wide | The facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. · from a complaint |
| May 27, 2025 | 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 |
| May 27, 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. · from a complaint |
| May 27, 2025 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · from a complaint |
| May 27, 2025 | C · Minimal risk, facility-wide | The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records. · from a complaint |
| May 30, 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. |
| May 30, 2024 | F · Potential for harm, facility-wide | The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records. |
| Aug 10, 2023 | 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. |
| Aug 10, 2023 | F · Potential for harm, facility-wide | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. |
| Aug 10, 2023 | F · Potential for harm, facility-wide | The facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. |
| Aug 10, 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. |
| Aug 10, 2023 | 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. |
| Aug 10, 2023 | F · Potential for harm, facility-wide | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| Aug 10, 2023 | F · Potential for harm, facility-wide | The facility did not have firmly secured handrails on both sides of its hallways. |
| Aug 10, 2023 | E · Potential for harm, repeated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. · from a complaint |
| Aug 10, 2023 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (2 → 3).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 9 | 0 | F |
| 2024 | 2 | 0 | F |
| 2025 | 13 | 1 | J ▲ |
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 $28,321, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| May 27, 2025 | Fine | $28,321 |
| May 27, 2025 | Payment Denial | 367 days from Jun 25, 2025 |
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) | 4.62 | 4.83 | 3.95 | bottom 43% in Minnesota; top 20% in the U.S. |
| Registered Nurse hours | 1.87 | 1.22 | 0.69 | top 7% in Minnesota; top 2% in the U.S. |
| Weekend total nurse staffing | 3.95 | 4.27 | 3.50 | bottom 37% in Minnesota; top 24% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.99 | 0.69 | 0.48 | top 17% in Minnesota; top 6% in the U.S. |
| Total nursing staff turnover (%) | 40.5 | 42.2 | 45.8 | bottom 48% in Minnesota; top 38% in the U.S. |
| RN turnover (%) | 11.1 | 38.6 | 42.9 | top 5% in Minnesota; top 4% 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 3.66, RN 1.48, weekend 3.13. 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: 4/5 · long-stay residents: 3/5 · short-stay residents: 4/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Bach, Curtis | Individual | Corporate Officer | NOT APPLICABLE | 08/28/2024 |
| Bach, Curtis | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/28/2024 |
| Bach, Curtis | Individual | ADP of the SNF | NOT APPLICABLE | 08/28/2024 |
| Big Stone Therapies, INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 02/03/2015 |
| Big Stone Therapies, INC | Organization | ADP of the SNF | NOT APPLICABLE | 10/23/2025 |
| Boesen, Lacey | Individual | ADP of the SNF | NOT APPLICABLE | 05/07/2024 |
| Caspers, Megan | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/29/2014 |
| Caspers, Megan | Individual | ADP of the SNF | NOT APPLICABLE | 12/29/2014 |
| Decker, Chad | Individual | Managing Control - Governing Body | NOT APPLICABLE | 01/01/2016 |
| Decker, Chad | Individual | Corporate Director | NOT APPLICABLE | 01/01/2016 |
| Decker, Chad | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2016 |
| Decker, Chad | Individual | ADP of the SNF | NOT APPLICABLE | 04/09/2025 |
| Dripps, Daniel | Individual | Corporate Director | NOT APPLICABLE | 01/01/2016 |
| Ehlers, Douglas | Individual | Managing Control - Governing Body | NOT APPLICABLE | 01/01/2023 |
| Ehlers, Douglas | Individual | Corporate Director | NOT APPLICABLE | 01/01/2023 |
| Ehlers, Douglas | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2023 |
| Ehlers, Douglas | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2023 |
| Eide Bailly LLP | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/03/2023 |
| Eide Bailly LLP | Organization | ADP of the SNF | NOT APPLICABLE | 10/23/2025 |
| Erickson-Linnell, Amelia | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/28/2025 |
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?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Before any service that isn't covered by Medicare or Medicaid, how will you notify us and get our agreement?"
- "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
- "Can you tell me about this citation and confirm your license and compliance status today?"
- "How do you decide you have enough staff and resources for your resident population, including nights and weekends?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "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 |
|---|---|---|---|---|---|
| Edenbrook Pine Haven | 6.1 mi | Pine Island, MN | ★★☆☆☆ | 3/5 | |
| Rochester Rehabilitation and Living Center | 17.2 mi | Rochester, MN | ★☆☆☆☆ | 1/5 | |
| Madonna Towers of Rochester | 18.1 mi | Rochester, MN | ★★★☆☆ | 3/5 | |
| St Crispin Living Community | 18.2 mi | Red Wing, MN | ★★★★☆ | 3/5 | |
| Edenbrook Rochester West | 19.2 mi | Rochester, MN | ★★☆☆☆ | 1/5 | |
| Edenbrook of Rochester | 19.4 mi | Rochester, MN | ★★☆☆☆ | 2/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 245376.