Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
ST THERESE OF WOODBURY LLC
WOODBURY, MN · 56 certified beds · Last Life Safety survey May 29, 2026
CMS Certification Number 245632 · first certified September 2016
Ownership
Operated by SAINT THERESE SENIOR COMMUNITIES · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within MN
15 citations — more than 64% of the 338 certified nursing homes in MN. Compared within MN rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 6 citations; the earlier surveys in the window averaged 4.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens May 2027 — about 7 months from now. This facility’s last Life Safety survey was May 2026. Facilities in MN are typically surveyed 11–14 months after the last one (median 13), measured over 613 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Emergency preparedness
4 of the 15 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 15 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in MN, and nationally. Surveyors differ markedly between states, so the MN figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 15 |
| Median facility in MN | 12 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| May 23, 2024 | 7 |
| March 20, 2025 | 2 |
| May 29, 2026 | 6 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2024-05-23 |
| K-0541 | Install properly constructed and protected linen or trash chutes. | 1 | 2024-05-23 |
| K-0311 | Have an enclosure around a vertical opening shaft. | 1 | 2026-05-29 |
| E-0026 | Establish roles under a Waiver declared by secretary. | 1 | 2024-05-23 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2026-05-29 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2026-05-29 |
| K-0930 | Ensure proper storage of liquid oxygen. | 1 | 2025-03-20 |
| E-0032 | Provide primary/alternate means for communication. | 1 | 2024-05-23 |
What the citations cover
- Smoke Deficiencies 5
- Emergency Preparedness Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Services Deficiencies 2
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 5 |
| Emergency Preparedness Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Services Deficiencies | 2 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
May 29, 2026 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (June 26, 2026) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (July 2, 2026) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (July 2, 2026) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (July 2, 2026) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 2, 2026) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (July 2, 2026) |
March 20, 2025 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (April 24, 2025) |
| K-0930 | Ensure proper storage of liquid oxygen. | Deficient, Provider has date of correction (April 24, 2025) |
May 23, 2024 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (June 25, 2024) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (June 25, 2024) |
| E-0032 | Provide primary/alternate means for communication. | Deficient, Provider has date of correction (June 25, 2024) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (June 25, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (June 25, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (June 25, 2024) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (June 25, 2024) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.