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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J1 | K· | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D14 | E2 | F6 |
| Minimal | A· | B· | C· |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| Sep 2, 2026 | Fire safety | Fire Safety Standard | 3 | Potential harm | — | Open → |
| Sep 2, 2026 | Health | Health Standard | 2 | Potential harm | 2 | Open → |
| Sep 19, 2025 | Health | Health Complaint | 1 | Actual harm | — | Open → |
| Sep 10, 2025 | Health | Health Standard | 4 | Potential harm | — | Open → |
| Jul 17, 2024 | Fire safety | Fire Safety Standard | 4 | Potential harm | — | Open → |
| Jul 17, 2024 | Health | Health Standard | 6 | Potential harm | — | Open → |
| May 2, 2024 | Health | Health Complaint | 1 | Immediate jeopardy | — | Open → |
| Feb 29, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Aug 10, 2023 | Fire safety | Fire Safety Standard | 1 | Potential harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| May 2, 2024 | Civil money penalty (fine) | $15,642 | — | 245243|Fine|53819 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J1 | K· | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D14 | E2 | F6 |
| Minimal | A· | B· | C· |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Sep 2, 2026 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Sep 24, 2026 | |
| Sep 2, 2026 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Sep 2, 2026 | |
| Sep 2, 2026 | K-0918 |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
CMS legal business name of the certified provider. Operates this facility only.
13 facilities in 3 states. CMS chain ID 61.
Chain average overall rating (CMS): 4.1
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Avera Marshall | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Jan 1, 2020 |
| Avera Health | Organization | Indirect owner | INDIRECT OWNERSHIP INTEREST | not provided | Jan 1, 2020 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Avera Marshall | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Jan 1, 2020 |
| Avera Health | Organization | Indirect owner | INDIRECT OWNERSHIP INTEREST | not provided | Jan 1, 2020 |
| Daniel Barber | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jul 1, 2024 |
| Mark Jensen | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jul 1, 2023 |
| Facility | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|
| Avera Morningside Heights Care Center 300 South Bruce Street, Marshall, MN 56258 CCN 245228 | 76 | Mar 24, 2026 | 211 IJ2 harm | $17k | |
| Avera Sunrise Manor 240 Willow Street, Tyler, MN 56178 CCN 245357 |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Parkview Home 102 County State Aid Highway 9, Belview, MN 56214 CCN 245475 | 1.6 km | 30 | May 6, 2026 | 281 IJ | $15k | |
| Luther Haven 1109 East Highway 7, Montevideo, MN 56265 CCN 245259 | 21.5 km | 55 | Sep 16, 2026 | 292 IJ1 harm10 open | $101k |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 245243 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 245243 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 245243 | county_fips County assigned by locating CMS coordinates in Census county boundaries (the CMS county name did not match the Census code list). | Inferred | Oct 1, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety |
| D · Potential harm Isolated |
| Corrected Sep 16, 2026 |
| Sep 2, 2026 | F-0628 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | No plan of correction |
| Sep 2, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | No plan of correction |
| Sep 19, 2025 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Past non-compliance Sep 12, 2025 | Complaint |
| Sep 10, 2025 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Nov 26, 2025 |
| Sep 10, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Nov 26, 2025 |
| Sep 10, 2025 | F-0882 | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Nov 26, 2025 |
| Sep 10, 2025 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Nov 26, 2025 |
| Jul 17, 2024 | K-0226 | Have horizontal exits used in accordance with safety requirements. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Sep 3, 2024 |
| Jul 17, 2024 | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Aug 8, 2024 |
| Jul 17, 2024 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Aug 8, 2024 |
| Jul 17, 2024 | K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Sep 3, 2024 |
| Jul 17, 2024 | F-0557 | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Aug 8, 2024 |
| Jul 17, 2024 | F-0576 | Ensure residents have reasonable access to and privacy in their use of communication methods. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Aug 8, 2024 |
| Jul 17, 2024 | F-0604 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 8, 2024 |
| Jul 17, 2024 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 8, 2024 |
| Jul 17, 2024 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 20, 2024 |
| Jul 17, 2024 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Aug 8, 2024 |
| May 2, 2024 | F-0678 | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. Quality of Life and Care Deficiencies · Clinical care | J · Immediate jeopardy Isolated | Past non-compliance Apr 30, 2024 | Complaint |
| Feb 29, 2024 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 21, 2024 | Complaint |
| Feb 29, 2024 | F-0773 | Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Mar 21, 2024 | Complaint |
| Aug 10, 2023 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Sep 6, 2023 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 5.70 (case-mix index 0.95).
| Lavonne Koenen | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jul 1, 2020 |
| Rosa Rios Avendano | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jul 1, 2023 |
| Lisa Streich | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jul 1, 2024 |
| Lucille Welbig | Individual | Operational / managerial control | MANAGING CONTROL - GOVERNING BODY | not provided | Jul 1, 2023 |
| Darrell Carter | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jan 1, 2020 |
| Thomas Kooiman | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jan 1, 2020 |
| Christy Coudron | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Sep 1, 2020 |
| Thomas Kooiman | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Jan 1, 2020 |
| Julie Lautt | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Mar 1, 2020 |
| Debra Streier | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Feb 1, 2021 |
| Darrell Carter | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Dec 16, 2025 |
| Thomas Kooiman | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Dec 16, 2025 |
| Julie Lautt | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Mar 1, 2020 |
| 30 |
| Jul 16, 2026 |
161 open |
| — |