Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lyngblomsten Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple diagnoses was left unsupervised to complete a nebulizer treatment without a required assessment or provider order for self-administration. Staff and record reviews confirmed that facility policy was not followed, as there was no documentation or authorization allowing the resident to self-administer medications.
A resident with severe cognitive impairment and mobility deficits was regularly placed in a recliner with the feet elevated and the remote out of reach, restricting independent movement. Staff and therapy confirmed no assessment or order justified the use of the recliner as a restraint, and documentation lacked evidence of evaluation or consent. The use of the recliner limited the resident's freedom of movement without proper assessment or authorization, resulting in a deficiency related to restraint use.
A resident's MDS assessment was inaccurately coded to indicate discharge to a hospital, while documentation and staff interviews confirmed the resident was actually discharged home to an assisted living facility and enrolled in hospice. The MDS coordinator and DON both acknowledged the error and confirmed that the assessment did not reflect the resident's true discharge status.
A resident who is deaf and uses ASL did not consistently receive communication support as outlined in their care plan, with staff often failing to use the iPad interpreter for care interactions and instead relying on written notes, despite the resident's clear preference for interpreter use. Only the social worker regularly used the interpreter, and several staff were unaware of or did not follow the resident's communication preferences.
Two residents with cognitive impairments and specific activity preferences were not consistently offered or included in individualized activities, and their participation was not documented as required. Observations, interviews, and record reviews showed that both residents were often left without engagement in preferred activities, with staff failing to implement or record activity offerings according to care plans and facility policy.
A resident with severe cognitive impairment and limited mobility was repeatedly transferred using a mechanical standing lift despite being unable to bear weight and having only one functional hand. Staff demonstrated inconsistent understanding of transfer criteria, and the resident was observed hanging from the lift during transfers. Facility policies required residents to bear weight and hold the lift handles, but staff failed to identify unsafe transfers or refer for reassessment, resulting in a deficiency.
A resident with multiple chronic conditions was administered a crushed extended-release blood pressure medication by a trained medication aide, who assumed it was safe to do so based on a general order to crush medications. Neither the aide nor the RN verified whether the extended-release formulation could be crushed, and the warning label was overlooked. The error was discovered only after the nurse practitioner was consulted, leading to a change in the medication order.
Survey results, including required CMS 2567 documentation for several complaint investigations and standard surveys, were not made readily accessible to residents, visitors, or families. The binder intended for survey results was missing key documents, and a resident confirmed that survey results were not available for review. No relevant policies were provided when requested.
Two residents with moderately impaired cognition had POLST forms inaccurately reflecting their resuscitation wishes, leading to an immediate jeopardy situation. Despite verbal confirmations of their DNR preferences, the forms indicated full code status due to errors by nursing staff. This discrepancy could have resulted in CPR being performed against the residents' wishes.
A resident with Alzheimer's and osteoarthritis fell from a sit-to-stand lift due to inadequate staff training and lack of proper assessment for lift use. The resident was left suspended while staff changed batteries, resulting in a fracture and tendon tear. The facility lacked a routine maintenance program and proper training on emergency lift functions.
Failure to Complete Assessment and Obtain Order for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a self-administration of medication (SAM) assessment was completed and a provider order was obtained for a resident to self-administer medications. The resident in question had severely impaired cognition, Alzheimer's disease, heart failure, and anxiety, and required significant assistance with personal and oral hygiene. Documentation showed that the resident did not wish to self-administer medications, and there was an active order stating the resident was not capable of safely self-administering medications. Despite this, staff left the resident unsupervised to complete a nebulizer treatment in her room, without a provider order or documented assessment supporting her ability to self-administer the treatment. Observation revealed that a trained medication aide set up the nebulizer treatment and left the resident alone in her room while the treatment was ongoing. The aide later confirmed that there was no provider order or assessment in place allowing the resident to self-administer the nebulizer treatment. Interviews with nursing staff and review of the resident's records confirmed that staff were expected to remain with the resident during such treatments and that the facility's policy required both an assessment and a provider order for self-administration. The facility's policy was not followed, resulting in the resident being left unsupervised during medication administration without the necessary documentation or authorization.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required, unless needed for medical treatment. The resident in question had severely impaired cognition, multiple neurological diagnoses including Parkinson's disease and dementia, and was dependent on staff for mobility and transfers. Despite these needs, the resident was regularly placed in a recliner in the common area with the feet elevated and the remote control out of reach, which restricted the resident's ability to get up independently. Staff interviews confirmed that the resident could not activate the chair and could not get up from the recliner without assistance. Documentation and care planning did not include a medical diagnosis or assessment justifying the use of the electric recliner as a restraint, nor was there an order for its use. The care plan addressed fall risk and mobility deficits but did not specify the use of the recliner as a restraint or include an assessment of the resident's ability to rise from it. Occupational therapy and the director of therapy confirmed that no assessment had been completed regarding the safety or appropriateness of the recliner for this resident, and the use of the recliner was not evaluated as a physical restraint. Family members and staff interviews indicated that the recliner was used as a means to prevent falls after bed alarms could no longer be used, and that no consent or waiver was signed for its use. Facility policy defined physical restraints as any device that restricts freedom of movement and cannot be easily removed by the resident, and required evaluation for such devices. The lack of assessment, documentation, and proper authorization led to the use of the recliner in a manner that restricted the resident's freedom of movement, constituting a deficiency in compliance with restraint regulations.
Inaccurate MDS Coding for Resident Discharge Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment was accurately coded to reflect the actual discharge status of a resident. Specifically, the MDS for one resident indicated a discharge to a short-term general hospital, while both the resident's progress notes and nursing progress notes documented that the resident was discharged home to an assisted living facility and had signed onto hospice care. This discrepancy was identified during an interview and document review, where the MDS coordinator confirmed the MDS was inaccurately coded and did not match the resident's actual discharge destination. The director of nursing also acknowledged that the MDS was expected to be accurate and that MDS coordinators are required to follow the MDS Resident Assessment Instrument (RAI) manual. The manual specifies that accurate assessments must be based on information from multiple sources, including the resident's medical record and direct care staff, and must reflect the resident's actual status during the observation period. In this case, the failure to accurately code the MDS assessment was confirmed by both the MDS coordinator and the director of nursing.
Failure to Provide Consistent ASL Interpreter Access for Deaf Resident
Penalty
Summary
A deficiency was identified when the facility failed to consistently provide appropriate communication support for a resident who was deaf and used American Sign Language (ASL) as their primary language. The resident's care plan and provider orders specified the need for an ASL interpreter, especially for significant interactions such as care conferences, assessments, and daily care activities. Despite these documented needs and preferences, staff interviews and resident statements revealed that the ASL interpreter, accessible via an iPad, was not regularly used. Instead, staff often relied on written communication, which the resident found confusing and inadequate, particularly when staff were non-English speaking or unfamiliar with ASL structure. The resident repeatedly expressed a preference for the ASL interpreter to be used for all care interactions, but this was not consistently honored. Multiple staff members, including nursing assistants, a trained medical aid, and a registered nurse, confirmed that they did not use the iPad interpreter during their interactions with the resident, often defaulting to written notes or yes/no questions. The social worker was identified as the only staff member who regularly used the iPad interpreter. The Director of Nursing acknowledged that the care plan required use of the ASL interpreter for major interactions and agreed that staff should follow the resident's stated preference. Facility policy also required interpreter use upon resident request and for key care communications, but this was not consistently implemented, resulting in a failure to meet the resident's communication needs as outlined in their care plan.
Failure to Provide and Document Individualized Activities for Residents
Penalty
Summary
The facility failed to ensure that individualized activities were provided and documented for two residents with cognitive impairments and specific activity preferences. For one resident with severe cognitive impairment, a history of loneliness, and interests in activities such as church, music, socialization, and gardening, there was little to no documentation of participation in activities over several months. Observations and interviews revealed that this resident was often found alone, either sleeping, sitting by the nursing station, or watching television, and expressed a desire to be kept busy. Family members reported a lack of available activities and noted that the resident would likely participate if activities were offered. Staff interviews confirmed that activities were not consistently offered or documented for this resident, and the responsible staff member acknowledged the failure to implement the resident's assessed preferences. Another resident with cognitive impairment, Parkinson's disease, and a preference for books, pets, news, religious activities, and outdoor activities also did not have documented participation in activities. The care plan indicated a need for encouragement to attend group programs and support for independent leisure activities, but both paper and electronic records lacked evidence of activity attendance. Family members and a privately paid companion reported that the resident was not invited to activities and that participation only occurred when facilitated by family. Staff interviews confirmed that the resident was not consistently invited to activities, and all recent participation had been with family members rather than facility staff. The facility's policy required comprehensive documentation of residents' interests and involvement in therapeutic recreation programs, including daily attendance records and regular care plan reviews. However, documentation and interviews revealed that these requirements were not met for the two residents reviewed. The lack of consistent offering, encouragement, and documentation of individualized activities led to the deficiency identified during the survey.
Failure to Assess and Safely Transfer Resident Using Mechanical Lift
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively assess a resident's transfer needs and did not develop or implement adequate policies to ensure safe and supervised transfers using a mechanical lift. The resident in question had severely impaired cognition, limited function in the right arm and hand, used a wheelchair, required maximal assistance for mobility, and was on hospice care. The care plan indicated the need for one to two staff for transfers with a mechanical lift, but the electronic medical record did not reflect a reassessment of transfer needs when the mechanical lift was used. Multiple observations showed the resident being transferred with a mechanical standing lift despite being unable to bear weight and having only one functional hand to hold the lift handle. Staff interviews revealed inconsistent understanding of the criteria for using the mechanical lift, with some staff expressing discomfort with the transfer process and others stating the resident met the criteria. During transfers, the resident was observed hanging from the lift, unable to support themselves, and required staff to lift their legs onto the foot plate. The director of therapy confirmed that the resident did not meet the qualifications for the mechanical standing lift and should not have been using it. Facility policies required that residents be able to bear weight and hold onto the lift handles to be suitable for standing transfers. However, the staff failed to identify that the resident's transfers were unsafe and did not refer the resident for a therapy reassessment when their abilities changed. The director of nursing acknowledged that while staff were aware of the transfer process, they did not recognize unsafe transfers, leading to the deficiency.
Crushing of Extended-Release Medication Results in Significant Medication Error
Penalty
Summary
A significant medication error occurred when a resident with diagnoses including reduced mobility, cardiac pacemaker, history of sudden cardiac arrest, Alzheimer's disease, and heart failure was administered metoprolol succinate extended-release in a crushed form. The resident's care plan indicated that medications could be crushed to aid swallowing, and the medication aide prepared and intended to administer several medications, including the extended-release metoprolol, in crushed form. The aide stated she had been crushing this medication for some time, assuming it was permissible due to the general order to crush medications, and did not notice the warning label on the medication card indicating it should not be crushed or chewed. Further interviews revealed that nursing staff were unaware that the extended-release formulation should not be crushed and had not verified this with the provider. The nurse practitioner, when contacted, confirmed that the medication should not be crushed and changed the order to a different formulation. The director of nursing acknowledged that extended-release medications should not be crushed unless specifically ordered and that it was the facility's responsibility to notify the provider if a medication needed to be changed to a crushable form. The facility's policy on crushing medications was requested but not provided.
Failure to Provide Accessible Survey Results to Residents and Families
Penalty
Summary
The facility failed to ensure that complaint investigation survey results were readily accessible and available for review within the campus. During a recertification survey, it was observed that the binder labeled as containing survey results, located near the front desk, did not include required CMS 2567 documentation for several abbreviated complaint surveys and a standard survey conducted on specific dates. Interviews with the administrator and DON confirmed that these survey results were missing from the binder, and a resident stated that survey results were not available for residents to review. Additionally, when policies related to survey results were requested, none were provided.
Inaccurate POLST Forms Lead to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that the Physician Order for Life Sustaining Treatment (POLST) accurately reflected the current resuscitation wishes for two residents, resulting in an immediate jeopardy situation. One resident, with moderately impaired cognition due to a stroke, had a POLST indicating full code status, contrary to their expressed wish for Do Not Resuscitate (DNR) status with comfort care. Despite the resident's verbal confirmation of their DNR preference, the POLST form was incorrectly filled out by a registered nurse, leading to a potential situation where cardiopulmonary resuscitation (CPR) would be performed against the resident's wishes. Similarly, another resident with moderately impaired cognition due to a femur fracture had a POLST indicating full code status, despite a provider order directing a change to DNR status. The resident also verbally confirmed their wish to be DNR, but the POLST form in their medical record was not updated to reflect this change. Staff members, including registered and licensed practical nurses, confirmed that they would rely on the paper POLST form to determine code status, which in these cases, would have led to actions contrary to the residents' wishes.
Failure to Ensure Safe Transfer with Mechanical Lift
Penalty
Summary
The facility failed to complete a safe transfer assessment for a resident using a sit-to-stand mechanical lift, resulting in a fall and subsequent injuries. The resident, who had Alzheimer's, dementia, and osteoarthritis, was on hospice care and required substantial assistance with daily activities. The care plan did not include specific interventions for the resident's behaviors during transfers, and there was no comprehensive assessment for the appropriate size and type of sling to be used with the mechanical lift. During the incident, the resident was left suspended in the lift while staff changed batteries, unaware of the emergency lowering features. The resident, unable to hold on due to weakness and osteoarthritis, let go and sustained a fracture and tendon tear. Interviews with staff revealed a lack of training on the emergency features of the lift and an absence of a system to ensure the correct sling size was used for each resident. Additionally, the facility did not have a routine maintenance program for the lifts, and staff were not adequately trained on the equipment's emergency functions. The incident highlighted several deficiencies, including inadequate staff training, lack of proper assessments for mechanical lift use, and failure to follow manufacturer instructions for lift maintenance. The resident's family had previously reported concerns about the lift, but these were not addressed. The facility's policies did not adequately cover the assessment and reassessment of residents' transfer needs, contributing to the incident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Saint Paul
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Anthony Park Home Inc | 1.7 mi | ★★★★★ | 1 | 0 |
| Episcopal Church Home The Gardens | 1.8 mi | ★★★★★ | 15 | 0 |
| Episcopal Church Home Of Minnesota | 1.9 mi | ★★★★★ | 17 | 1 |
| The Estates At Lynnhurst Llc | 1.9 mi | ★★★★★ | 1 | 0 |
| The Villas At Roseville | 2.4 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.