Edenbrook Pine Haven
210 Northwest 3rd Street · Pine Island, MN · 55963 · 5073568304
70 certified beds Non profit - Corporation
Why this verdict
- Staffing levels are well below research benchmarks for safe care.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
74% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 3 of 5 Staffing: 1 of 5 Quality measures: 1 of 5
| Total nurse hours / resident-day | — | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | — | 0.55–0.75 |
| Weekend hours / resident-day | — | ≈ weekday level |
| Nursing turnover / year | 74% | median 45% |
| Fines (3-yr window) | 1 · $14,898 |
Inspection citations (28 in the current record)
-
Potential for harm · E August 28, 2025
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected October 15, 2025 · Resident Rights
-
Potential for harm · D August 28, 2025
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected October 15, 2025 · Resident Rights
-
Potential for harm · D August 28, 2025
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected October 15, 2025 · Resident Rights
-
Potential for harm · D August 28, 2025
Provide safe, appropriate pain management for a resident who requires such services.
Corrected October 15, 2025 · Quality of Life and Care
-
Potential for harm · D August 28, 2025
Provide and implement an infection prevention and control program.
Corrected October 15, 2025 · Infection Control
-
Potential for harm · D August 28, 2025
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected October 15, 2025 · Infection Control
-
Potential for harm · D December 24, 2024 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected January 31, 2025 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D December 24, 2024 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected January 31, 2025 · Quality of Life and Care
-
Potential for harm · D October 3, 2024 · found via complaint
Provide safe and appropriate respiratory care for a resident when needed.
Corrected November 8, 2024 · Quality of Life and Care
-
Potential for harm · D October 3, 2024 · found via complaint
Provide and implement an infection prevention and control program.
Corrected November 8, 2024 · Infection Control
-
Potential for harm · D July 17, 2024
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected August 26, 2024 · Resident Rights
-
Potential for harm · D July 17, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected August 26, 2024 · Resident Assessment and Care Planning
-
Potential for harm · D July 17, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected August 26, 2024 · Quality of Life and Care
-
Potential for harm · D July 17, 2024
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected August 26, 2024 · Quality of Life and Care
-
Potential for harm · D July 17, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Corrected August 26, 2024 · Quality of Life and Care
-
Potential for harm · D July 17, 2024
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected August 26, 2024 · Quality of Life and Care
-
Potential for harm · D July 17, 2024
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected August 26, 2024 · Pharmacy Service
-
Potential for harm · D July 17, 2024
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected August 26, 2024 · Pharmacy Service
-
Potential for harm · E July 17, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected August 26, 2024 · Nutrition and Dietary
-
Potential for harm · F July 17, 2024
Provide and implement an infection prevention and control program.
Corrected August 26, 2024 · Infection Control
-
Potential for harm · D July 17, 2024
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected August 26, 2024 · Infection Control
-
Actual harm · G January 23, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected January 17, 2024 · Quality of Life and Care
-
Potential for harm · D January 23, 2024 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected February 16, 2024 · Resident Assessment and Care Planning
-
Potential for harm · D August 24, 2023
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected October 4, 2023 · Resident Rights
-
Potential for harm · F August 24, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected September 22, 2023 · Nutrition and Dietary
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| January 23, 2024 | Fine | $14,898 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 245359 · certified since November 1, 1986. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.