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Nursing HomeMedicaid Investigative

Guardian Angels Care Center

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

400 Evans Avenue, Elk River, MN 55330120 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
3.9/5

based on 31 Google reviews

5
4
3
2
1
Guardian Angels Care Center Nursing Home in Elk River, MN — Street View
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3/ 10
moderate Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (2/5 stars)
  • High RN turnover (61%)

Below average in MN · Meets national RN staffing standard · Above recommended total nurse staffing · $98,353 in fines · Very few deficiencies

Source: Medicare data

What this means for your family

This facility is often praised for its clean environment and skilled therapy team, making it a potential option for short-term rehab. However, families must be aware of recurring reports regarding slow response times to call lights and staffing shortages. We strongly recommend visiting during off-hours or weekends to observe staffing levels firsthand before making a decision.

Google Reviews

Google Reviews

31 reviews on Google
Guardian Angels Care Center receives polarized feedback, with many families praising the facility for its clean, home-like environment and compassionate individual staff members. However, significant concerns persist regarding chronic understaffing, leading to long wait times for call lights and potential lapses in basic care and medication management. Families should weigh the positive experiences in physical therapy and rehabilitation against reports of inconsistent responsiveness and administrative issues.

Quality Themes

Tap a score for details
Food2.0Staff6.0Clean9.0ActivitiesN/AMeds3.0MemoryN/AComms5.0Value1.0

Strengths

  • Clean, well-maintained facility
  • Effective physical and occupational therapy
  • Compassionate and friendly individual staff members
  • Helpful administrative and business office support

Concerns

  • Slow response times to call lights (mentioned by 3 reviewers)
  • Inconsistent or poor quality of food (mentioned by 2 reviewers)
  • Understaffing impacting care quality (mentioned by 3 reviewers)

Rating Trends

Tap a year to see what changed

234'16(2)'18(1)'20(3)'22(1)'24(7)'26(8)

Distribution · 36 analyzed

5
23
4
5
3
0
2
2
1
6

How They Respond to Reviews

23%response rate

This facility rarely responds to reviews.

Questions for Your Tour

  • 1I noticed the facility has a strong reputation for physical and occupational therapy; how do you integrate those services into a resident's daily routine?
  • 2Could you walk me through your current process for responding to call lights and how you ensure residents receive timely assistance?
  • 3We understand that dining is a major part of daily life; what steps are you taking to improve the variety and quality of the meal service?
  • 4Given the current staffing levels, how do you ensure that each resident receives consistent, personalized attention throughout the day?
  • 5What is your protocol for medication management, and how do you keep families informed if there are any changes or concerns regarding a resident's health?
  • 6I see that you engage with feedback online; how does that input from families help you make specific improvements to the care provided at Guardian Angels?

Personalized based on this facility's data


Key Review Excerpts

The business office staff has been so very helpful with the county and financial questions. When you have never gone through anything like this before...you don't know what you don't know!

Long-term resident's family · 2023★★★★★

The staff took forever to show up when you push the button for help. There were times it was 45 minutes before anyone showed up to help. Then they would leave my grandma on the toilet for 20 minutes alone sometimes before coming back to help her off.

Rehab patient's family · 2023☆☆☆☆

On the 3rd shift, the nurse was good as when I asked for pain meds I got right away. Zeke, the aide was exceptional. He was the best. He was caring and attentive and would make sure he did everything possible to make me comfortable.

Rehab patient · 2025★★★★★
Source: 31 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
1.48hrs
OK
Registered nurses for medical care
Total Nursing
4.87hrs
OK
All nurses + aides combined
Staff Turnover
54%
Lower is better (< 30% = good)
RN Turnover
60%
Lower is better (< 30% = good)

This facility meets the national staffing benchmarks. Higher staffing is linked to fewer falls and better day-to-day care.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
3/ 5
Better Than Avg

13

measures

Worse Than Avg

3

measures

Mixed Results

1

measures

Long-Stay Residents
🚶

Residents whose walking got worse

↓ Lower is better
This Facility42.2%
Worse than Avg
Here
42.2%
US
15.3%
MN
21.4%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility4.9%
Better than Avg
Here
4.9%
US
19.5%
MN
12.5%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility33.2%
Worse than Avg
Here
33.2%
US
19.4%
MN
24.5%
😔

Residents with depression symptoms

↓ Lower is better
This Facility4.3%
Better than Avg
Here
4.3%
US
12.1%
MN
4.3%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility99.3%
Better than Avg
Here
99.3%
US
93.4%
MN
97.3%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility14.0%
Better than Avg
Here
14.0%
US
14.4%
MN
18.6%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility97.1%
Better than Avg
Here
97.1%
US
79.8%
MN
82.7%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility95.6%
Better than Avg
Here
95.6%
US
81.8%
MN
88.3%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility2.0%
Worse than Avg
Here
2.0%
US
1.6%
MN
1.8%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

2deficiencies
5penalties
Well below state avg (8.0)
7 complaint-triggered
$98,353 in fines

This facility has faced nine complaint-triggered deficiencies over recent years, indicating families have filed reports about care concerns. The most recurring issues involve resident rights violations, quality of care problems, and fire safety deficiencies. While all deficiencies show correction dates, the pattern of repeated complaints about resident dignity, care planning, and safety supervision suggests ongoing challenges in core care areas that families should carefully evaluate during visits.

Mar 19, 2026Complaint
1
0690Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Dec 10, 2025Routine
3
0321Potential for harm · IsolatedCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0930Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper storage of liquid oxygen.

0918Minimal · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Sep 9, 2025Complaint
1
0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Apr 24, 2025Complaint
1
0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Jan 24, 2025Routine
14
0880Immediate jeopardy · WidespreadCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0677Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0804Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

0321Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0353Potential for harm · PatternCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0372Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0226Potential for harm · IsolatedCorrected

Egress Deficiencies

Have horizontal exits used in accordance with safety requirements.

0324Potential for harm · IsolatedCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0923Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

0521Minimal · WidespreadCorrected

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Sep 12, 2024Complaint
1
0558Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

Federal Penalties

Fine

Jan 24, 2025

$59,010

Payment Denial

Jan 24, 2025

26-day denial

Fine

Jul 17, 2024

$13,627

Fine

May 16, 2024

$16,801

Fine

Mar 14, 2024

$8,915

Ownership & Operations

Who Operates This Facility

Owner / Operator

Guardian Angels Care Center

Organization Type

nonprofit

Ownership & Management

Key personnel

Sonntag, RobertContracted Managing EmployeeHeinecke, CarlieW-2 Managing EmployeeLarson, TraciW-2 Managing EmployeeMcdevitt, DeanW-2 Managing EmployeeLeclaire, JoyceOfficer / Director
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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