Cycle 1
Health 2025-06-16 · Fire 2025-06-16
22 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Excelsior, MN
The Estates at Excelsior LLC
1-star overall rating with 1-star inspections with abuse icon flag with 22 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
515 Division Street, Excelsior, MN
(952) 474-5488
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
45
Certified beds
Average residents
29
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Monarch Healthcare Management
Operator or chain grouping
Approved since
1986-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
45 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.29
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.43
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
1.72
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
3.44
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.72
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.04
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
1.03
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.55
CMS adjusted RN staffing hours
Adjusted total hours
4.15
CMS adjusted total nurse staffing hours
Case-mix index
1.13
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,928
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.01
Composite VBP score used to determine payment impact.
Payment multiplier
0.9828
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.91
Baseline 20.33% · Performance 20.08% · Measure score 2.91 · Achievement 2.91 · Improvement 0.26
Healthcare-associated infections
3.63
Baseline 5.64% · Performance 6.75% · Measure score 3.63 · Achievement 3.63 · Improvement 0
Total nurse turnover
0
Performance 65.39% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.26
Baseline 3.80 hours · Performance 3.72 hours · Measure score 2.26 · Achievement 2.26 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.11% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 5.77% · Lower 95% interval 6.72% |
| Discharge to community | 51.29% |
50.57%
0.7 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 48.94% · Lower 95% interval 38.48% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 28 · Denominator 28 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 28 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 28 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.75% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 26 · Observed rate 3.85% · Lower 95% interval 3.58% |
| Staff COVID-19 vaccination coverage | 1.75% |
8.2%
6.4 pts worse
|
Numerator 1 · Denominator 57 |
| Staff flu vaccination coverage | 23.81% |
42%
18.2 pts worse
|
Numerator 15 · Denominator 63 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.4% |
97.3%
4.9 pts worse
|
93.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 92.0% · Q2 91.7% · Q3 90.0% · Q4 95.7% · 4Q avg 92.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.3% |
3.9%
0.4 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.2% · Q3 5.0% · Q4 8.7% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 13.2% |
4.3%
8.9 pts worse
|
11.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · 4Q avg 13.2% |
| Percentage of long-stay residents who lose too much weight | 1.4% |
4.1%
2.7 pts better
|
5.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.5% · 4Q avg 1.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.2% |
12.4%
3.8 pts worse
|
19.6%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 18.2% · 4Q avg 16.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.8% |
17.5%
4.3 pts worse
|
16.7%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.6% |
22.5%
14.9 pts better
|
16.3%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.2% |
18.6%
10.6 pts worse
|
14.9%
14.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.5% · Q2 38.1% · 4Q avg 29.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
2.3%
1.2 pts better
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.6%
2.6 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.6% |
24.8%
2.2 pts better
|
19.8%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 25.7% · Q4 17.8% · 4Q avg 22.6% |
| Percentage of long-stay residents with pressure ulcers | 6.8% |
5.4%
1.4 pts worse
|
5.1%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 12.8% · Q3 3.0% · Q4 3.0% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.4% |
88.6%
5.2 pts worse
|
81.7%
1.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.2% · Q2 74.6% · Q3 82.7% · Q4 91.2% · 4Q avg 83.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.6% |
14.0%
5.4 pts better
|
12.0%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.6% · Observed 11.1% · Expected 14.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 6.2% |
1.9%
4.3 pts worse
|
1.6%
4.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.4% · Q3 4.8% · Q4 12.1% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 65.6% |
82.7%
17.1 pts worse
|
79.7%
14.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 65.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.2% |
23.1%
11.1 pts worse
|
23.9%
10.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.2% · Observed 38.9% · Expected 27.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-16 · Fire 2024-05-16
9 health deficiencies
Top issue: Infection Control (3 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2023-06-02 · Fire 2023-06-02
13 health deficiencies
Top issue: Resident Rights (6 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-16
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-07-30
F · Potential for more than minimal harm
2024-05-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-07
E · Potential for more than minimal harm
2024-05-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-06-07
F · Potential for more than minimal harm
2023-06-02
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-07-28
F · Potential for more than minimal harm
2023-06-02
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-07-28
F · Potential for more than minimal harm
2023-06-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-02
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-08-07
Inspection history
Recent health citations
J · Immediate jeopardy
2025-11-26
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Not marked corrected
F · Potential for more than minimal harm
2025-06-16
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2025-07-30
F · Potential for more than minimal harm
2025-06-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-07-30
F · Potential for more than minimal harm
2025-06-16
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-07-30
F · Potential for more than minimal harm
2025-06-16
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-07-30
F · Potential for more than minimal harm
2025-06-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-30
E · Potential for more than minimal harm
2025-06-16
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-07-30
E · Potential for more than minimal harm
2025-06-16
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-30
E · Potential for more than minimal harm
2025-06-16
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-07-30
D · Potential for more than minimal harm
2025-06-16
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-07-30
D · Potential for more than minimal harm
2025-06-16
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-07-30
D · Potential for more than minimal harm
2025-06-16
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-07-30
D · Potential for more than minimal harm
2025-06-16
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-07-30
D · Potential for more than minimal harm
2025-06-16
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-07-30
D · Potential for more than minimal harm
2025-06-16
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-07-30
D · Potential for more than minimal harm
2025-06-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-30
D · Potential for more than minimal harm
2025-06-16
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-07-30
D · Potential for more than minimal harm
2025-06-16
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-07-30
D · Potential for more than minimal harm
2025-06-16
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-07-30
D · Potential for more than minimal harm
2025-06-16
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-07-30
D · Potential for more than minimal harm
2025-06-16
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-07-30
D · Potential for more than minimal harm
2025-06-16
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-07-30
D · Potential for more than minimal harm
2025-01-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-28
D · Potential for more than minimal harm
2024-11-07
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-11-29
F · Potential for more than minimal harm
2024-05-16
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-06-18
E · Potential for more than minimal harm
2024-05-16
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2024-06-18
E · Potential for more than minimal harm
2024-05-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-18
D · Potential for more than minimal harm
2024-05-16
F625 · Resident Rights Deficiencies
Health
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 2024-06-18
D · Potential for more than minimal harm
2024-05-16
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-06-18
D · Potential for more than minimal harm
2024-04-25
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-05-08
D · Potential for more than minimal harm
2023-08-11
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-08-11
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-08-11
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-08-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-09-01
F · Potential for more than minimal harm
2023-06-02
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2023-07-28
E · Potential for more than minimal harm
2023-06-02
F826 · Quality of Life and Care Deficiencies
Health
Provide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-02
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-02
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-02
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-02
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-28
C · Minimal harm
2023-06-02
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-07-28
Penalties and ownership
What sits behind the stars
Ownership
Halpert, Marc
5% Or Greater Indirect Ownership Interest · Individual
Legum, Joshua
5% Or Greater Indirect Ownership Interest · Individual
Spartan Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Yazoma Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
Stern, William
5% Or Greater Direct Ownership Interest · Individual
Arem, Jeffrey
5% Or Greater Indirect Ownership Interest · Individual
Jaffa, Noam
5% Or Greater Indirect Ownership Interest · Individual
Nij LLC
5% Or Greater Direct Ownership Interest · Organization
Halpert, Marc
Corporate Officer · Individual
Legum, Joshua
Corporate Officer · Individual
Legum, Joshua
W-2 Managing Employee · Individual
Monarch Healthcare Operating Iv LLC
Operational/Managerial Control · Organization
Stern, William
Operational/Managerial Control · Individual
Stern, William
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Hope Springs at Minnetonka
Minnetonka, MN
1-star overall rating with 1-star inspections with $9,496 in total fines with 16 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Lake Minnetonka Shores
Spring Park, MN
5-star overall rating with 4-star inspections with $8,827 in total fines
#3
Folkestone
Wayzata, MN
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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