Mount Olivet Home
5517 Lyndale Avenue South, Minneapolis, MN 55419 · Non profit - Corporation · 92 certified beds · (612) 827-5677 Medicaid only — no Medicare
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (19% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 1 actual-harm citation
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 10.2% | 18.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.3% | 4.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.9% | 1.9% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 0.0% | 2.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 4.8% | 4.1% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.5% | 4.0% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 4.8% | 20.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 14.4% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 99.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.8% | 5.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 14.5% | 24.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 26.8% | 17.1% | 17.1% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.48 | 1.61 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.44 | 1.90 | 1.80 | better |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Staffing
How full it usually is: this home is certified for 92 beds and averages 84.1 residents a day — about 91% occupied, or roughly 8 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.68 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.83 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.72 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.11 hrs/resident/day on weekends vs 2.91 on weekdays — 28% thinner on weekends — a notable drop. RN hours go from 0.99 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 19% is below the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
17 citations, most serious first. The 11 most serious are shown; the remaining 6 are one tap away and print in full.
- Actual harm · Gcited before2025-04-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY R5 R5's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), orthostatic hypotension, and a history of falls. It further indicated impairment on bilateral lower extremities (LE), independent with toileting and mobility, was occasionally incontinent of urine and always continent of bowel. Shortness of breath (SOB) when laying flat, had a fall within the last 2-6 months prior to admission/entry or reentry, and received an antidepressant and diuretic on a routine basis. R5's Care Area Assessment (CAA) triggered for falls from the MDS (11/27/25) for the following reasons: -new admit -advanced age -history of falls -impaired mobility (uses a wheelchair and was able to self-transfer with walker) -COPD with oxygen use as needed (PRN), CHF, bilateral (both sides) LE edema, morbid obesity, chronic pain, Benign Prostatic Hyperplasia (BPH) with occasional urinary incontinence, hypertension (HTN), atrial…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-05-14 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure 1 of 1 commercial can opener was kept in a clean and sanitary manner and failed to ensure dry goods removed from original packaging were stored in a manner to reduce the risk of cross-contamination. These findings had the potential to affect all 80 residents, staff, and visitors who consumed food prepared from the main production kitchen.Findings include:During initial tour with director of culinary services (DCS) on 5/11/26 at 11:10 a.m., a series of 4 white-colored plastic bins were observed in the food preparation area. The wheeled bins were on the floor and were labeled for flour, white sugar, rice and powdered sugar. The flour bin was approximately 1/3 full of white flour and a black-colored scoop was inside, partially covered with flour including the scoop's handle. The bin labeled white sugar had a yellowish-tan dry matter inside the right lateral wall. The inside front wall of the bin had red dry matter 6-7 centimeters (cm)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-14 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to provide a dignified experience for 1 of 2 residents (R20) who was receiving medications. Findings include: R20's annual Minimum Data Set (MDS) dated [DATE], indicated severely impaired cognition, inattention, disorganized thinking, verbal behaviors toward others and other behavioral symptoms. It further included diagnoses of dementia (severe with psychotic disturbance), visual hallucinations, general anxiety disorder, post-traumatic stress disorder (PTSD), and delusional disorder. R20's care area assessment (CAA) also dated 3/18/26, triggered for cognitive loss/dementia due to being unable to respond to questions on the Brief Interview for Mental Status (BIMS) assessment due to cognition and had diagnoses of Alzheimer's disease, dementia, visual hallucinations and delusional disorder. R20's care plan dated 3/12/26, indicated R20 had an alteration in mood/behavior/sleep due to diagnoses of Alzheimer's disease, dementia, generalized…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure personal hygiene care (i.e., nail care, hair washing, showers) was provided for 1 of 1 resident (R36) reviewed for activities of daily living (ADLs) and who was dependent on staff for his care. Findings include: R36's comprehensive Minimum Data Set (MDS) dated [DATE], indicated R36 had severe cognitive impairment, verbal behaviors, refused bathing, needed moderate assistance with toileting, and needed supervision/touching assistance to put on shoes, dress his upper body, and for personal hygiene. R36's diagnosis list indicated Alzheimer's disease, parkinsonism and high blood pressure. R36's care plan reviewed 5/11/26, indicated R36 had a potential for alteration in completion of ADLs, due to diagnosis of Parkinson's disease. Care plan's goal indicated R36 will maintain good oral hygiene with/without assistance, and will be neat, clean and odor free. The care plan directed staff to assist R36 with bathing, grooming and lower body…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-04-30 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and document review, the facility failed to ensure food items were labeled and dated, three of three kitchenettes were not properly cleaned per facility policy and cleaning log manual. This had the potential to affect all residents whom consumed beverages from the kitchenettes. During the initial observation of kitchenette on 2nd floor on 4/28/25 at 2:04 p.m., there was one filled frozen dixie cup no name or label in freezer, and one 20-ounce bottle of Gatorade one third opened no name or label in refrigerator. The ice/water machine had white flaky substance on back by dispenser. Folgers coffee machine had scant amount of brown tinged dried brown liquid on bottom of grate. Observed on 4/28/25 at 2:14 p.m., dietary aide-A verified refrigerator/freezer temperatures and documented findings on the log, removed labeled and covered food items from refrigerator, did not observe cleaning of any machines. Interview on 4/28/25 at 2:25 p.m. with NAR -A, confirmed the observation of the machines. They stated all items are to be labeled and dated in refrigerator…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-30 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to develop and implement a comprehensive care plan to include identified trauma-related triggers and individualized trauma-informed care approaches for 2 of 2 residents (R14, R77) who had a history of trauma. Findings include: R14 R14's quarterly Minimum Data Set (MDS) dated [DATE], indicated she had intact cognition and reported diagnoses of anxiety, depression, bipolar disorder (a mental disorder characterized by episodes of extreme elevated mood, or mania, and depression), and post traumatic stress disorder (PTSD, a psychiatric disorder that some people who have experienced or witnessed distressing or life-threatening event(s) may develop). Per a trauma informed care/vulnerabilities assessment dated [DATE], R14 indicated she had experienced trauma that was so frightening, horrible, tragic, or upsetting she had a hard time not thinking about it. The assessment identified her traumatic experiences and reported she was physically, sexually, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-30 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure wound care orders were followed and implemented for 1 of 3 residents (R27) reviewed for skin conditions. Findings include: R27's annual Minimum Data Set (MDS) dated [DATE], indicated R27 had intact cognition, did not have impairment with range of motion, used a walker, was independent with toileting hygiene, personal hygiene, transfers, and ambulation, and required substantial assistance with showering and bathing. Further, R27 was not on a toileting program, occasionally was incontinent of urine and was always continent of bowels, was not at risk for pressure ulcers and did not have other skin problems including moisture associated skin damage (MASD). R27's Medical Diagnosis form indicated the following diagnoses: retention of urine, muscle weakness, osteoarthritis, and history of falling. R27's care plan dated 3/13/25, indicated R27 had a potential for alteration in skin integrity due to urinary incontinence, skin was intact…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-30 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure identified triggers were documented in the comprehensive care plan and individualized trauma-informed approaches were utilized for 2 of 2 residents (R14, R77) who had a history of trauma. Findings include: R14 R14's quarterly Minimum Data Set (MDS) dated [DATE], indicated she had intact cognition and reported diagnoses of anxiety, depression, bipolar disorder (a mental disorder characterized by episodes of extreme elevated mood, or mania, and depression), and post traumatic stress disorder (PTSD, a psychiatric disorder that some people who have experienced or witnessed distressing or life-threatening event(s) may develop). Per a trauma informed care/vulnerabilities assessment dated [DATE], R14 indicated she had experienced trauma that was so frightening, horrible, tragic, or upsetting she had a hard time not thinking about it. The assessment identified her traumatic experiences and reported she was physically, sexually, and emotionally abused.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-30 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to collaborate with hospice for the development, implementation, and revision of the coordinated plan of care for 1 of 1 residents (R34) reviewed for hospice services. Findings include: R34's significant change Minimum Data Set (MDS) dated [DATE], indicated she had severely impaired cognition and received hospice care. The MDS identified diagnoses of Alzheimer's disease (a progressive brain condition that affects thinking, memory, and behavior), non-Alzheimer's dementia (symptoms characterized by problems with memory, thinking, and behavior), depression, and anxiety. R34's care plan revised 4/7/25, identified she was on hospice care related to her Alzheimer's dementia diagnosis and directed staff to work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs were met. R34's hospice plan of care dated 4/4/25, identified coordination of care between the facility, hospice team, and her and her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-06-27 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure proper sanitization of dishware used for meal prep and resident service when the high temperature sanitizing dishwasher was not reaching adequate wash and rinse temperatures. This had the potential to impact all 92 residents who reside in the facility. Findings include: Ecolab EC-66HH specifications sheet dated 2012, indicated the dishwasher operating temperatures for high temp wash was 160 degrees F. The operating temperature for sanitizing rinse was 180 degrees F. A facility document titled Culinary Services Dish Washer Temperature Log dated 6/2024, indicated logged final rinse temperatures hit 180 degrees F one time from 6/1/24-6/26/24. An observation on 6/26/24 at 7:46 a.m., dietary aide (DA)-A started to wash breakfast prep dishes. The dishwasher was from Ecolab. There were two temp gauges one for wash and one for rinse. On the wash temp dial was a small sticker stated wash temp 150 and on the other temp dial was a small sticker stated final rinse temp 180. The first rack of pans went through. An…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-06-27 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure insulin was to be administered to the correct resident and failed to ensure appropriate medication receiving procedures were followed for 1 of 3 residents (R18) observed for insulin administration. Additionally, the facility failed to provide pharmaceutical services to meet each resident's needs which included receiving the correct resident's medications and disposing of a discharged resident's medications. This had the potential to affect all who residents who received insulin residing in the facility. Findings include: R18's quarterly Minimum Data Set (MDS) dated [DATE], indicated R18 had moderate cognitive impairment and diagnoses of heart failure, renal failure, diabetes mellitus, and dementia. R18's order summary report dated 6/27/24, directed staff to subcutaneously inject R18 with 5 units of insulin aspart solution 100 unit/mL with meals for diabetes and hold if blood sugar less than 120. During observation on 6/26/24 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 6 citations
- Potential for harm · E2024-06-27 · tag F0761 — failed to label and store drugs safely — patternEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure insulin pens were labeled in accordance with professional standards for 2 of 3 residents observed during insulin administration. Furthermore, the facility failed to ensure insulin pen-injectors were stored in a locked compartment. This had the potential to affect all 31 residents residing on the locked memory care unit. Findings include: R18's quarterly Minimum Data Set (MDS) dated [DATE], indicated R18 had moderate cognitive impairment and diagnoses of heart failure, renal failure, diabetes mellitus, and dementia. R18's order summary report dated 6/27/24, directed staff to subcutaneously inject R18 with 5 units of insulin aspart solution 100 unit/mL with meals for diabetes and hold if blood sugar less than 120. R53's quarterly MDS dated [DATE], indicated R53 had intact cognition and diagnoses of diabetes mellitus and dementia. R53's order summary report dated 6/27/24, directed staff to subcutaneously inject R53 with 6 units of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-27 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to accommodate resident preference and assist in maintaining and/or achieving independent functioning for 3 of 3 residents (R16, R60, R61) reviewed who expressed a desire to open the windows in their rooms as they wished. Findings include: R16's quarterly Minimum Data Set (MDS) dated [DATE], indicated R16 was cognitively intact, had diagnoses of depression, macular degeneration (an age-related eye condition that affects vision,) heart failure, and kidney failure, and was independent with transfers and ambulation. R16's annual MDS 7/19/23, indicated R16's daily preferences were not assessed. R16's care plan dated 9/24/21, included R16 was legally blind and used a walker for mobility. During observation and interview on 6/24/24 at 12:54 p.m., R16 was seated in a chair in their room which had two crank-out style windows without cranks. R16 stated the facility took all the window cranks off because the state directed them to do so, and stated,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure an electric lift chair was assessed for safe use for 1 of 1 residents (R11) reviewed for positioning. R11's quarterly Minimum Data Set (MDS) dated [DATE], indicated R11 had cognitive impairment and diagnoses of osteoporosis (disease causing weak bones), spinal stenosis (narrowing of the spinal column) and dementia. Furthermore, R11's MDS indicated R11 required partial to moderate assist from sit to stand and used a walker for mobility. R11's physical device data assessment dated [DATE], indicated R11 was not assessed for safe use of an electric lift chair. R11's care plan dated 5/7/24, indicated R11 required staff assistance as needed for transfers. R11's care plan lacked indication R11 used an electric lift chair or required assistance with use. R11's [NAME] dated 6/25/24, lacked indication R11 used an electric lift chair or required assistance with use. R11's provider and nursing orders reviewed 6/24/24, lacked indication R11 used…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-27 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to implement resident-specific non-pharmacological interventions to address pain according to the resident's goals and preferences for 1 of 1 residents (R15) reviewed for pain. Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE], included they were moderately cognitively impaired, had diagnoses of rheumatoid arthritis, osteoarthritis, depression, and psychotic disorder, and was independent with ambulation. R15 received scheduled pain medications, did not receive PRN (as needed) medications, and did not receive non-pharmacological interventions for pain. R15 indicated they had frequent pain in the previous five days and rated it at a level four on a 1-10 scale. R15's pain Care Area Assessment (CAA) dated 2/13/24, included R15 has frequent/chronic bilateral knee pain with the pain intensity of 4 with contributory factors including a diagnosis of arthritis and low back pain. They received acetaminophen (a drug used to treat…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-27 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure nonpharmacological interventions were utilized before use of an as needed (PRN) antipsychotic medication and failed to ensure PRN antipsychotic medication was ordered for 14-day use for 1 of 1 residents (R9) reviewed for PRN antipsychotic medication use. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated R9 was cognitively intact and had diagnoses of anxiety disorder and bipolar disorder (mood disorder). Furthermore, R9 had exhibited no behaviors and routinely took an antipsychotic medication (medication used to treat mental/mood disorders). R9's provider order dated 6/4/24, indicated R9 required Seroquel 12.5 milligrams (mg) (antipsychotic medication used to treat mental/mood disorders) for every 12 hours PRN anxiety/bipolar disorder. This order had no end date. R9's medication administration record (MAR) and treatment administration record (TAR) dated 6/4/2024, indicated R9 did not require behavior interventions as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-27 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and document review, the facility failed to ensure hand hygiene and glove change occurred between dirty and clean tasks and a shared glucometer (blood glucose meter) was disinfected between 3 of 3 residents (R53, R18, R28) observed during blood sugar checks. Findings include: R53's order summary report dated 6/27/24, directed staff to check R53's blood glucose at 7:00 a.m. and 5:00 p.m. every other day and 11:00 a.m. and 8:00 p.m. the opposite days. R18's order summary report dated 6/27/24, directed to staff to check R18's blood glucose before meals and at bedtime. R28's physician's orders, directed staff to check R28's blood glucose before meals and at bedtime with revised date of 3/21/24. During observation on 6/26/24 at 7:23 a.m., RN-D entered R53's room with a caddy basket which contained items such as a glucometer, lancets, alcohol wipes, test strips, and insulin pens. RN-D completed hand hygiene and donned gloves. RN-D wiped R53's finger with an alcohol wipe and pricked R53's finger with a lancet. RN-D squeezed blood from R53's finger but…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
What families pay in MN
CMS lists this home as Medicaid-certified only — it can accept Medicaid for long-term care, but it is not Medicare-certified, so Medicare will not pay for a short rehabilitation (“skilled nursing”) stay here. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Minnesota Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 24E102. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-14, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.