Home / Minnesota / Granite Falls
Avera Granite Falls Care Center
250 Jordan Drive, Granite Falls, MN 56241 · Yellow Medcine County · (320) 564-3111
48 certified beds, about 46 residents a day · Non profit - Church related · Medicare and Medicaid since 1981
Certified for Medicaid Certified for Medicare
Overall
3 of 5
Health inspections
2 of 5
Staffing
5 of 5
Quality measures
4 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 245243 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on September 10, 2025, inspectors cited 4 health deficiencies (the Minnesota average is 7.1, the national average 9.2).
Of 17 health citations since August 2023, 2 were rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).
CMS lists 1 fine totaling $15,642 in the last three years; the largest was $15,642, and the latest is dated May 2, 2024.
Nurses and nurse aides worked 3.81 hours per resident per day, against 4.19 across Minnesota and 3.86 nationally. Registered nurses accounted for 0.82 of those hours.
25.0% of nursing staff left within the year CMS measured (Minnesota average 42.2%).
CMS links it to Avera Health, an affiliated group of 13 nursing homes.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
308/23
202/24
105/24
607/24
409/25
109/25
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 17 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
10D
2E
3F
Potential for minimal harm
0A
0B
0C
September 19, 2025Complaint inspection · 1 citation
- G Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review the facility failed to ensure a mechanical lift sling was properly secured and free from entanglement hazards following transfer and/or prior to wheelchair transport for 1 of 3 residents (R1) which resulted in harm when R1's left leg became entangled in the strap which caused a traumatic hematoma on the leg that required hospitalization, surgical intervention, and blood transfusion. The facility implemented immediate corrective action, so the deficient practice was issued at past non-compliance (PNC).
September 10, 2025Standard inspection · 4 citations
- F Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview and document review, the facility failed to ensure employee illnesses were tracked to identify when employees would be able to return to work after an illness, dependent upon their symptoms and resolution of illness for 3 of 3 staff nursing assistant (NA)-A, NA-B, and infection preventionist (IP)-A. This had the potential to affect all 48 residents who resided at the facility.
- F Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 1 infection preventionist (IP) had appropriate training and oversight of the infection control (IC) program by management by performing current, daily cumulative infection control surveillance activities, maintain documentation of incidents, findings, and any corrective actions required, and ensure the IC program continued while the newly hired IP completed training.
- D Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, and document review, the facility failed to establish an effective system of monitoring for expired medication and ensure expired medication was not used for 1 of 1 resident (R5).
- D Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 5 sampled residents (R24) was offered and/or provided updated vaccinations for pneumococcal disease, in accordance with Centers for Disease Control (CDC).
July 17, 2024Standard inspection · 6 citations
- F Ensure residents have reasonable access to and privacy in their use of communication methods.
Inspectors wroteBased on interview, the facility failed to ensure mail was consistently delivered to residents on Fridays and Saturdays. This had the potential to affect all 48 residents in the facility who received personal mail, including but not limited to, 5 of 5 residents (R1, R22, R28, R30 and R38) who verbally confirmed mail was not consistently received on Fridays and Saturdays.
- E Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a homelike, dignified dining experience was provided for 1 of 4 residents (R36). This had the potential to affect all 21 residents who ate meals in the Neighborhood A dining room. Findings Include: R36's 6/26/24, annual Minimum Data Set (MDS) assessment identified she had admitted to the facility in July of 2022, her cognition was intact, and she was independent with activities of daily living (ADL's). Observation on 7/15/24 at 12:17 p.m., registered nurse (RN)-A gathered supplies and insulin pen from the medication cart near the resident dining room. RN-A walked through the dining room and approached a table that had 4 residents (R8, R11, R36, and R22) seated and eating dinner. [...]
- D Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure residents were free from physical restraints for 1 of 1 resident (R14) who utilized a self-release belt as a restraint
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, interview, and document review, the facility failed to revise the care plan for 1 of 1 resident (R14) who utilized a self-release belt, she was unable to release.
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review the facility failed to groom [ROOM NUMBER] of 1 resident (R22) to maintain their highest practicable well-being.
- D Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and document review, the facility failed to ensure insulin was administered timely for 1 of 1 resident (R27).
May 2, 2024Complaint inspection · 1 citation
- J Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Inspectors wroteBased on interview and document review, the facility failed to follow physician orders for full code and did not initiate cardiopulmonary resuscitation (CPR) as per the residents wishes for 1 of 3 residents (R1) who wanted CPR. R1 was found without a pulse or respirations, staff did not initiate CPR and R1 expired and resulted in an immediate jeopardy (IJ). The facility implemented immediate corrective action prior to survey and IJ was issued at past noncompliance. The IJ began on [DATE], at approximately 1:00 a.m. when R1 was noted to have no respirations with a fast heart rate, and CPR was not initiated. The administrator and director of nursing (DON) were notified of the immediate jeopardy on [DATE] at 4:27 p.m. The facility implemented corrective action on [DATE], and the IJ was issued at past non compliance.
February 29, 2024Complaint inspection · 2 citations
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and document review the facility failed to comprehensively assess and monitor for fluid overload for 1 of 1 resident (R7) who had a diagnosis of congestive heart failure.
- D Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on document review and interview the facility failed to ensure that laboratory test were followed by provider timely for 1 of 1 (R7) resident for reporting of lab results.
August 10, 2023Standard inspection · 3 citations
- E Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and document review, the facility failed to ensure 4 of 5 residents (R13, R32, R34, and R37) were appropriately vaccinated against pneumococcal disease upon admission and/or offer updated vaccination per Centers for Disease Control (CDC) vaccination recommendations. This had the ability to affect all 30 residents.
- D Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview and document review, the facility failed to notify the county (designated State Mental Health Authority) for 1 of 1 resident (R32) with new onset mental illness.
- D Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview and document review the facility failed to accurately reconcile 1 of 1 resident's (R12) lorazepam (narcotic anti-anxiety medication) upon receipt from the pharmacy and ensure 2 of 2 resident's (R99 and R33) medications were immediately removed from the medication cart and not co-mingled and stored with in-use medication for other residents.
Fire safety inspections
6 fire safety citations on file: 4 on July 17, 2024, 1 on August 10, 2023, 1 on June 30, 2022.
Every fire safety citation6 citations
- F Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- E Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- D Have horizontal exits used in accordance with safety requirements.
- D Install emergency lighting that can last at least 1 1/2 hours.
- D Have approved installation, maintenance and testing program for fire alarm systems.
- F Inspect, test, and maintain automatic sprinkler systems.
Fines and payment denials
| Date | Penalty | Amount or length |
|---|---|---|
| May 2, 2024 | Fine | $15,642 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Minnesota | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.81 | 4.19 | 3.86 |
| Registered nurses | 0.82 | 1.06 | 0.69 |
| All nursing staff on weekends | 3.43 | 3.71 | 3.42 |
| Nurse aides | 2.69 | ||
| Licensed practical nurses | 0.30 | ||
| Nursing staff turnover (share who left in a year) | 25.0% | 42.2% | 45.8% |
| Registered nurse turnover | 25.0% | 38.6% | 42.9% |
| Administrators who left | not reported |
CMS expects 2.70 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.97 on weekdays and 3.43 on weekends, 14% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.4% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.84 in April to June 2025 to 3.81 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.81 | 0.82 | 3.97 | 3.43 | 0.4% | 0 of 90 | 46 |
| Oct to Dec 2025 | 3.71 | 0.94 | 3.89 | 3.26 | 0.0% | 0 of 92 | 46 |
| Jul to Sep 2025 | 3.92 | 1.02 | 4.10 | 3.43 | 0.0% | 0 of 92 | 46 |
| Apr to Jun 2025 | 3.84 | 1.09 | 4.10 | 3.21 | 0.0% | 0 of 91 | 46 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Minnesota, Jan to Mar 2026 | 4.19 | 1.05 | 4.38 | 3.73 | 5.2% | 0.8% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Minnesota | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 13.1 | 18.2 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.4 | 1.9 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.1 | 2.6 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 3.4 | 4.0 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.0 | 1.9 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 15.2 | 20.5 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 3.8 | 5.2 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 3.0 | 17.1 | 15.4 |
Owners and operators
Legal business name: AVERA GRANITE FALLS. CMS links this home to Avera Health, a group of 13 nursing homes averaging 3.8 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Avera Marshall | 5% or greater direct ownership interest | Organization | 100% | 01/01/2020 |
| Avera Health | Indirect ownership interest | Organization | 01/01/2020 | |
| Barber, Daniel | Managing control - governing body | Individual | 07/01/2024 | |
| Jensen, Mark | Managing control - governing body | Individual | 07/01/2023 | |
| Koenen, Lavonne | Managing control - governing body | Individual | 07/01/2020 | |
| Rios Avendano, Rosa | Managing control - governing body | Individual | 07/01/2023 | |
| Streich, Lisa | Managing control - governing body | Individual | 07/01/2024 | |
| Welbig, Lucille | Managing control - governing body | Individual | 07/01/2023 | |
| Coudron, Christy | Corporate officer | Individual | 09/01/2020 | |
| Kooiman, Thomas | Corporate officer | Individual | 01/01/2020 | |
| Lautt, Julie | Corporate officer | Individual | 03/01/2020 | |
| Streier, Debra | Corporate officer | Individual | 02/01/2021 | |
| Carter, Darrell | Operational/managerial control | Individual | 01/01/2020 | |
| Kooiman, Thomas | Operational/managerial control | Individual | 01/01/2020 | |
| Carter, Darrell | Adp of the SNF | Individual | 12/16/2025 | |
| Kooiman, Thomas | Adp of the SNF | Individual | 12/16/2025 | |
| Lautt, Julie | Adp of the SNF | Individual | 03/01/2020 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 4 problems in this area, most recently on September 19, 2025: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
- What changed in infection control since the last inspection, and who on staff is the infection preventionist?Inspectors cited 4 problems in this area, most recently on September 10, 2025: "Provide and implement an infection prevention and control program."
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 3 problems in this area, most recently on September 10, 2025: "Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 2 problems in this area, most recently on July 17, 2024: "Ensure residents have reasonable access to and privacy in their use of communication methods."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.43 hours per resident per day, below the Minnesota average of 3.71.
Other nursing homes nearby
- Parkview Home Belview, 1 mi · 3 of 5 stars · 20 citations
- Clara City Care Center Clara City, 12.8 mi · 1 of 5 stars · 12 citations
- Luther Haven Montevideo, 13.4 mi · 1 of 5 stars · 29 citations
- Clarkfield Care Center Clarkfield, 14.2 mi · 4 of 5 stars · 9 citations
- Renvilla Health Center Renville, 15.4 mi · 5 of 5 stars · 11 citations
Minnesota contacts for a concern about a nursing home
These are the official offices in Minnesota. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Minnesota Department of Health, Health Regulation Division, the state agency that inspects nursing homes for CMS and takes complaints about care.
- State inspection reports: MDH Nursing and Boarding Care Home Survey and Complaint Inspection Findings, where Minnesota publishes its own records on licensed homes.
Common questions
- What is Avera Granite Falls Care Center's Medicare star rating?
- CMS rates Avera Granite Falls Care Center 3 out of 5 stars overall, with 2 for health inspections, 5 for staffing and 4 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Avera Granite Falls Care Center get at its last inspection?
- 4 health deficiencies at the standard inspection on September 10, 2025. The Minnesota average is 7.1.
- Has Avera Granite Falls Care Center been fined?
- Yes. CMS lists 1 fine totaling $15,642 in the last three years.
- Does Avera Granite Falls Care Center accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Avera Granite Falls Care Center?
- CMS lists 17 owners and managers, and links the home to Avera Health. Legal business name: AVERA GRANITE FALLS.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.