Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 St Paul's Senior Community during CMS and state inspections, most recent first.
A resident with a stage 4 coccyx pressure ulcer, total dependence for ADLs, and continuous incontinence was care planned and ordered to be turned/repositioned at least every two hours, have moisture barrier applied with each incontinent episode, and receive specific daily wound care. Over several hours of observation, the resident remained in a wheelchair without repositioning or incontinence checks, and reported that staff did not check, change, or turn her every two hours and that she had not had a pressure ulcer before admission. A CNA confirmed residents should be turned and changed every two hours but stated it was hard to complete rounds due to staffing, while the ADON and IP said they expected two-hour checks, changes, and repositioning and acknowledged there was no formal turning/repositioning policy, only a general protocol for residents with wounds.
The facility failed to serve meals at safe and palatable temperatures when turkey wraps, vegetables, and sweet potato fries were prepared and distributed without proper temperature control or documentation. The dietary director identified that turkey wraps were above the required cold-holding temperature and placed them in the freezer, but they remained above 41°F when later checked. On a nursing unit, a dietary aide found hot items below the required hot-holding temperature, briefly returned them to the oven, and then served multiple residents without rechecking temperatures. A subsequent sample tray showed the entrée and sides at temperatures below facility standards for both hot and cold foods, and the food temperature log lacked required reheating temperatures despite a policy mandating corrective actions and documentation when items are out of range.
A resident with paraplegia, cognitively intact and independent with eating on a carbohydrate-controlled diet, reported that meals were consistently cold and lacked flavor. A test tray taken after meal service showed hot food items, including beef tacos, broccoli, and rice, were below the facility’s preferred 120°F standard, and the broccoli was mushy and light green. Resident Council minutes documented ongoing concerns about cold and overly spicy food. The DON acknowledged an expectation that staff follow the facility’s policy requiring daily monitoring of food temperatures to ensure palatability.
The facility did not post daily nurse staffing information in a prominent, accessible location for residents and visitors. Staff reported that nursing assignments were kept near the employee time clock or on individual papers rather than being publicly displayed in the lobby or on resident units. The ADON and DON acknowledged that staffing information was not posted where residents or visitors could see it and that there was no policy in place for nurse staffing posting. This deficiency had the potential to affect all 99 residents in the facility.
Staff Cell Phone Use During Work Hours: A CNA and an LPN were observed using personal cell phones during work hours in resident care areas, despite the facility policy prohibiting cell phone use while on duty except during breaks. Two residents with moderate cognitive impairment were identified in the deficiency review; one resident stated staff are frequently on their phones, and another had a grievance about cell phone use during meals and in general. The facility's resident rights policy states residents have the right to dignity and communication without interference.
Failure to Follow Approved Menus: The facility did not follow its approved menu for two residents reviewed for dietary services. One resident with Alzheimer's disease and a mechanical soft diet order was served turkey or ham instead of the sausage listed on the breakfast menu because the ordered item had not yet arrived. Another resident with moderate cognitive impairment and a controlled carbohydrate, no added salt diet stated the facility does not always serve what is listed on the menu; the DON stated menus should be followed as prescribed.
A resident with age-related physical debility, muscle wasting and atrophy, and moderate cognitive impairment reported that meals were sometimes served cold. Resident council minutes also identified cold food as a concern, and the DON stated food should consistently be served hot. The facility policy stated meal temperatures would be monitored daily to ensure food is served at palatable temperatures.
A resident with paraplegia and neurogenic bladder experienced pain and catheter displacement after a CNA failed to follow proper catheter care procedures, including pulling on the catheter tubing and not securing the leg strap correctly. The incident resulted in a hospital visit and was attributed to inadequate staff competency in catheter management.
Three residents with complex medical needs reported that food was often cold, unappetizing, and sometimes late. Direct observation found hot food items, such as gravy, were not kept at the required temperature, and staff confirmed food was not maintained in the warmer as expected. Resident council minutes and grievances documented ongoing concerns about cold food.
Two residents with special dietary needs reported that alternative menu items were frequently unavailable, with one resident stating that requests for alternatives were routinely denied and another not requesting alternatives due to past unavailability. Staff confirmed that certain alternative foods were sometimes out of stock, and no facility policy on alternative menus was provided when requested.
Two residents did not consistently receive diets as ordered or the full number of menu items due to the facility running out of food or not preparing all items for special diets. Staff confirmed that individuals on mechanical soft or pureed diets often received only two items instead of the three or four listed on the menu, and grievances documented issues such as incomplete meals, lack of protein, and repeated menu items.
The facility failed to provide adequate respiratory care for several residents, leading to significant health issues. One resident with COPD did not receive ordered nebulizer treatments, resulting in chest pain and decreased oxygen saturation. Another resident was found without a nasal cannula, despite needing continuous oxygen therapy, and was left alone with critically low oxygen levels. Additional residents experienced issues with oxygen management, including empty tanks and incorrect flow rates. The staff's failure to follow policies and communicate effectively contributed to these deficiencies.
The facility failed to maintain the dignity of three residents, leading to feelings of embarrassment and frustration. One resident was left in soiled conditions for over 30 minutes, while another was instructed to soil herself due to inadequate staffing. A third resident, the President of the Resident Council, reported feeling belittled by staff. These incidents highlight the facility's failure to uphold its Resident Rights Policy.
A facility failed to provide adequate staffing, impacting resident care. One resident was left in a soiled state due to delayed staff response, while another experienced a delay in oxygen concentrator checks. A third resident was told to soil herself due to insufficient staff. Staffing records confirmed only one CNA was available on a unit, contrary to usual staffing levels. The facility lacked a formal staffing policy, relying on state guidelines.
A resident with multiple medical conditions was unsafely transferred using a full body mechanical lift by a single CNA due to staffing shortages. The CNA did not lock the wheelchair, leaving the resident free-swinging in the air, contrary to the facility's policy and lift device manual, which recommend two assistants for safe operation.
Two residents experienced inadequate incontinent care, affecting their dignity and hygiene. A resident with multiple medical conditions was left soiled for over 30 minutes, and a CNA failed to perform proper peri-care. Another resident with end-stage renal disease was instructed to soil herself due to staffing issues, impacting her dignity. The facility did not adhere to proper care procedures, compromising resident care.
A resident with COPD and acute respiratory failure did not receive continuous oxygen therapy as ordered, due to staff oversight and equipment malfunction. The resident's oxygen concentrator was found off and beeping, and staff failed to maintain the prescribed oxygen level. The resident's daughter also noted incorrect oxygen settings on separate occasions, indicating a systemic issue with oxygen administration in the facility.
The facility failed to properly store and label food, affecting all 103 residents. Observations revealed multiple instances of unlabeled and undated food items, including cheese, rice, eggs, and expired yogurt, across various kitchen units and resident refrigerators. Despite a policy requiring labeling, the Dietary Manager confirmed the oversight, posing a risk of contamination.
The facility did not submit the required PBJ data for the 4th quarter of 2024, affecting all 103 residents. The report showed low weekend staffing, RN coverage for 8 hours/day, and licensed nurse coverage for 24 hours/day, leading to a one-star staffing rating. The Administrator stated the data was sent to the corporate office but not to CMS due to a new employee. The facility also lacked a policy for PBJ data submission.
A facility failed to notify a resident's family of a pneumonia diagnosis, despite the resident's daughter filing a grievance about not being informed of x-ray results. The daughter, who was concerned about her mother's symptoms, was not notified until she visited the facility. The responsible LPN received a write-up and re-education on family notification policies.
Two residents reported that staff frequently used personal cell phones during care, leading to confusion and irritation. Despite repeated concerns raised in Resident Council Meetings, the facility lacked a policy on cell phone use, violating resident rights to dignity and respect.
A facility failed to provide proper incontinent care and infection control, leading to a UTI in a resident. Observations showed CNAs not changing gloves or performing hand hygiene between tasks, and residents reported delays in receiving care. Staff interviews revealed a lack of consistent adherence to hygiene protocols, and the facility lacked a specific policy on incontinent care.
The facility failed to follow infection control practices, particularly in glove changing and hand hygiene, during care for three residents. CNAs did not change gloves or perform hand hygiene between tasks, violating the facility's policies. This was observed during peri-care for residents with multiple health conditions, including urinary tract infections.
A resident with Alzheimer's Disease, chronic pain syndrome, and vascular dementia requiring substantial assistance for transfers sustained bilateral femur fractures due to a Certified Nurse's Aide (CNA) attempting a solo transfer against the care plan's 2-person assist directive. The incident occurred late in the evening, and the absence of proper equipment like a gait belt or sit-to-stand device was noted. The facility's documentation highlighted non-adherence to the care plan and transfer protocols. Medical professionals confirmed the severity of the injuries, with osteopenia complicating surgical intervention, leading to the resident's death.
Failure to Provide Timely Turning and Incontinence Care for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely turning/repositioning and incontinence care to prevent the worsening and development of pressure ulcers for one resident at very high risk. The resident had diagnoses including a stage 4 sacral pressure ulcer, osteoarthritis of both hands, and peripheral vascular disease, and was dependent on staff for all ADLs with continuous bowel and bladder incontinence. Her care plan identified impaired skin integrity related to a coccyx pressure injury, pain, incontinence, decreased mobility, and poor circulation, and noted that she sometimes refused repositioning. Interventions in the care plan and physician orders included assistance with turning/repositioning at least every two hours, application of moisture barrier with each incontinent episode, floating heels, use of heel protectors, and specific daily wound care and dressing changes for the coccyx wound, with ongoing monitoring and documentation of wound characteristics. Despite these identified needs and interventions, observations over several hours showed the resident sitting in her wheelchair without any repositioning or incontinence checks. The resident reported that she did not have a pressure ulcer before admission and stated that staff did not check, change, or turn her every two hours. A CNA acknowledged that residents should be turned, repositioned, and changed every two hours but reported difficulty completing rounds due to feeling there was not enough staff. The ADON and Infection Preventionist both stated they expected residents to be checked, changed, and repositioned at least every two hours, and the ADON reported there was no formal turning and repositioning policy, only a general protocol to turn residents with wounds every two hours to relieve pressure.
Failure to Serve Meals at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable and safe temperatures for multiple residents during a lunch meal service. On the day of survey, the dietary director (V3) reported that turkey wraps with sweet potato fries, mixed vegetables, and pudding were being served. V3 stated that all wraps were temperature-checked before being placed in coolers and would be re-checked on the units, and calibrated the surveyor’s thermometer to 32.5°F, indicating a 0.5°F adjustment. At 11:47 AM, the turkey wraps measured 49.8°F, and V3 placed them in the freezer, stating that hot food would be sent out first so it could be placed in ovens while the cold food was brought to proper temperature. At 12:07 PM, after time in the freezer, the wraps were rechecked at 45°F and returned to the freezer. At 12:14 PM, food arrived on the 2 South unit and the dietary aide (V4) began preparations to serve. V4 checked the mixed vegetables at 132°F and the sweet potato fries at 134.5°F, stated these were not warm enough, and placed them back in the oven. V4 checked the turkey wraps at 43.4°F at 12:20 PM and left them out over ice. At 12:25 PM, V4 began serving the meal to residents, including R1, R6, R7, R8, and R9, without rechecking any food temperatures. At 1:00 PM, a sample tray taken after all residents were served showed the following temperatures: turkey wrap 43.2°F, mixed vegetables 102°F, sweet potato fries 97.6°F, pureed wrap 65.7°F, pureed vegetables 103.8°F, and pureed sweet potato fries 114.5°F. The facility’s Food Holding Temperature Log for 2 South documented an entrée at 43.4°F, vegetable at 132°F, and starch at 134°F, with no reheating temperatures recorded, despite the log and the facility’s policy requiring hot foods to be 140°F and above, cold foods 41°F and below, and documenting corrective actions and new temperatures when reheating or chilling is required.
Failure to Provide Palatable Food at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that food was appetizing and served at a palatable temperature for one resident reviewed for food and nutritional services. The resident, who was cognitively intact, had paraplegia, was independent with eating, and was on a carbohydrate-controlled diet, reported that the food was always cold and lacked flavor. A test tray conducted after the last resident tray was served showed that the beef tacos measured 110°F, the broccoli 107°F, and the rice 101°F, which were below the facility’s preferred standard of 120°F or greater for hot foods on room trays at the point of service to promote palatability. The broccoli on the test tray was observed to be mushy and light green in color. Resident Council meeting minutes from two separate months documented ongoing concerns about cold food and food being too spicy. The DON stated an expectation that the facility adhere to its policy regarding food temperature and palatability, and the facility’s undated policy documented that food temperatures would be monitored daily to ensure foods are served at palatable temperatures.
Failure to Post Daily Nurse Staffing Information in Accessible Locations
Penalty
Summary
The facility failed to post daily nurse staffing information in a prominent place that was readily accessible to residents and visitors, affecting all 99 residents. On 1/8/26 at 8:32 AM, the receptionist stated that nursing assignments were posted only by the employee time clock, and there was no visible staffing information in the front lobby. Subsequent observations on the same date at multiple times showed no nurse staffing postings on Units 1-South, 1-North, 2-North, 2-South, 3-South, or 3-North. The ADON confirmed that daily nurse staffing assignments were not posted where residents and visitors could see them, and a nurse manager stated that staffing was not posted for visitors, explaining that if a visitor wanted to know who was caring for a resident, the nurse would check paperwork instead. An LPN reported that she kept nursing assignments on paper but did not post them for residents or visitors. The DON acknowledged that the facility had not been posting staffing information and did not have a policy regarding nurse posting, stating they would just follow the regulations. The CMS Form 802 dated 1/6/26 documented that 99 residents were living in the facility.
Staff Cell Phone Use During Work Hours
Penalty
Summary
The facility failed to ensure 2 of 4 residents reviewed for resident rights were treated with dignity and respect because staff were observed using personal cell phones excessively during work hours. On 11/21/25 at 2:19 PM, a CNA was sitting at a table in the 1 South Dining Room looking at a cell phone. On 11/22/25 at 5:20 AM, an LPN was sitting at the 1 South Nurse's Station looking at a cell phone, and at 5:25 AM, another CNA was sitting at a table in the 1 South Dining Room looking at a cell phone. The facility's Employee Handbook states that cellular phones are strictly prohibited while on duty except during scheduled rest and meal periods, and the Resident Rights Policy states residents have the right to a dignified existence and communication without interference. R3's Face Sheet documented diagnoses including age related physical debility and muscle wasting and atrophy, and the MDS documented moderate cognitive impairment. On 11/21/25 at 11:00 AM, R3 stated staff are frequently on their cell phones at work. R5's Face Sheet documented diagnoses including hemiplegia and need for assistance with personal care, and the MDS documented moderate cognitive impairment. R5's grievance dated 9/26/25 documented cell phone use during meals and in general as a complaint. The DON stated on 11/21/25 that staff are not to be on cell phones during work hours, and the ADON stated on 11/25/25 that staff are not allowed to use their cell phones unless they are on break or off the unit.
Failure to Follow Approved Menus
Penalty
Summary
The facility failed to follow its approved menu for 2 of 4 residents reviewed for dietary services. One resident had a face sheet documenting admission with Alzheimer's disease and a diet order for a mechanical soft diet. The facility's mechanical soft menu for breakfast listed ground sausage links, and the meal ticket also documented ground sausage. However, during breakfast service, a dietary aide began plating food, and the resident was later served a breakfast tray containing cubes of a white-colored meat approximately one-half inch in size instead of the sausage listed on the menu. Staff on the unit identified the meat as turkey or baked ham, and the Assistant Dietary Manager stated the resident received turkey because the sausage had not yet come in on the food truck, so some turkey was chopped up for him. A second resident had diagnoses including age-related physical debility and muscle wasting and atrophy, with an MDS documenting moderate cognitive impairment and a diet order for a controlled carbohydrate, no added salt diet. The resident stated the facility does not always serve what is listed on the menu. The DON stated menus should be followed as prescribed, while the facility's Guidelines for Menu Planning from the 2012 Long Term Care Diet Manual did not address adhering to prescribed menus.
Cold Food Served at Meals
Penalty
Summary
The facility failed to provide meals at palatable temperatures for 1 of 4 residents reviewed for food and nutritional services. The resident, who had diagnoses including age-related physical debility and muscle wasting and atrophy, was moderately cognitively impaired per the MDS and was ordered a carbohydrate controlled, no added salt diet. During interview, the resident stated that sometimes the food is served cold. The Resident Council Meeting Minutes also documented cold food as an issue or concern, and the DON stated that food should consistently be served hot. The facility’s Monitoring Food Temperatures for Meal Service policy stated that food temperatures would be monitored daily to prevent foodborne illness and ensure foods are served at palatable temperatures.
Inadequate Catheter Care Competency Leads to Resident Harm
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to demonstrate appropriate competency in the care of a resident with an indwelling urinary catheter. The resident, who had paraplegia and neuromuscular dysfunction of the bladder, required an indwelling catheter and was dependent on staff for transfers and partial assistance with mobility. According to documentation and interviews, the CNA pulled on the resident's catheter while attempting to empty the catheter bag, resulting in the catheter leaking urine and causing the resident pain. The resident reported that the CNA was rough and did not follow the correct procedure, which led to a hospital visit for catheter displacement. The resident also expressed a preference not to have that CNA provide care in the future. Further investigation revealed that the CNA attempted to lift the mattress to remove the catheter bag, which is not in accordance with facility procedures. The leg strap securing the catheter tubing was not properly positioned, and the CNA acknowledged that it should have been placed higher on the leg or not used at all, as the resident typically did not wear it. The facility's policy requires that catheter tubing be secured with a leg strap to prevent movement and trauma. Staff interviews confirmed that the CNA did not follow established procedures for catheter care, resulting in the incident.
Failure to Serve Palatable and Appropriately Tempered Food
Penalty
Summary
The facility failed to provide appetizing food at palatable and safe temperatures for three out of five residents reviewed for food and nutrition services. Residents with complex medical conditions, including end stage renal disease, pressure ulcers, and muscle wasting, reported that the food was consistently cold, unappetizing, and sometimes arrived late. One resident with a pureed diet and mechanical soft preferences, as ordered by a Speech Language Pathologist, also expressed ongoing dissatisfaction with food quality. Grievances and resident council meeting minutes documented repeated concerns about cold food. Direct observation during meal service revealed that hot food items, such as gravy, were not maintained at appropriate temperatures, with a measured temperature of 105°F, below the facility's policy preference of 120°F or greater for palatability. The gravy was left on the counter without a method to keep it warm, and staff acknowledged this lapse. Facility policy and staff interviews confirmed the expectation that food should be served at acceptable temperatures, but this standard was not met during the survey period.
Failure to Provide Consistently Available Alternative Menu Options
Penalty
Summary
The facility failed to ensure that always available alternative food options were provided to residents as required. One resident with a renal diet and multiple complex medical conditions, including a stage 3 sacral pressure ulcer, extensive burns, and dependence on dialysis, reported that although an alternative menu existed, the items requested were consistently unavailable. This resident was cognitively intact and able to communicate these concerns directly. Another resident, with a pureed diet and double portions per SLP orders, also reported that the facility was frequently out of food items and did not request alternatives because he believed they would not be provided. This resident was moderately cognitively impaired. Interviews with facility staff confirmed that alternative menu items such as chicken strips and French fries were sometimes unavailable. The Regional Director of Operations/Interim Administrator acknowledged that while the alternative menu should be available from 7:00 AM to 7:00 PM, there were instances when certain foods were not in stock. Additionally, when the facility's policy regarding alternative menus was requested, no policy was provided. The facility's documented alternative menu included a variety of choices, but these were not consistently accessible to residents.
Failure to Provide Diets as Ordered and Follow Pre-Planned Menus
Penalty
Summary
The facility failed to provide diets as ordered and did not follow pre-planned menus for two of four sampled residents. One resident, who is cognitively intact and on a consistent carbohydrate diet, reported not always receiving the food items ordered from the menu due to the facility running out of food or not having the listed items available. Another resident, who is mildly cognitively impaired and requires supervision or assistance with eating, stated she is on a mechanical soft diet but often receives only two items on her tray instead of the three or four items listed on the menu. Multiple grievances documented issues such as not offering different drink choices, serving incomplete meals, not providing breakfast to early dialysis patients, lack of protein in meals, poor food quality, repeated menu items, and food being cold or missing from trays. Interviews with staff, including the interim Certified Dietary Manager, LPNs, Activities Assistant, and CNA, confirmed that residents on special diets such as mechanical soft or pureed were not consistently receiving the full menu as ordered, often receiving only two items instead of the required three or four. Staff acknowledged that not all menu items were prepared for residents with special diets, particularly on weekends. The facility's policy requires that the nutritional needs of residents be met according to recommended dietary allowances and that menus be prepared and presented as planned, which was not consistently followed.
Inadequate Respiratory Care and Oxygen Management
Penalty
Summary
The facility failed to provide adequate respiratory care for several residents, leading to significant health issues. One resident, who was admitted with acute on chronic congestive heart failure, lymphedema, and chronic obstructive pulmonary disease (COPD), did not receive the ordered nebulizer treatments. This resident experienced chest pain, tightness, shortness of breath, and decreased oxygen saturation levels. Despite having orders for breathing treatments, the resident reported not receiving them, and the staff failed to administer the treatments as scheduled. The resident's oxygen levels were inconsistently monitored, and there was a lack of communication among staff regarding the resident's treatment needs. Another resident, with diagnoses including congestive heart failure and COPD, was observed without a nasal cannula attached, despite orders for continuous oxygen therapy. The resident's oxygen saturation levels were critically low, yet the staff failed to respond appropriately. The resident was left alone with low oxygen levels, and the staff did not communicate the resident's condition to the nursing team. This lack of attention and communication resulted in the resident being taken to physical therapy without proper oxygen support. Additional residents also experienced issues with their oxygen therapy. One resident was found with an empty oxygen tank, and another was receiving oxygen at an incorrect flow rate. The facility's policies on oxygen administration and medication were not followed, leading to inaccurate documentation and failure to administer necessary treatments. The staff's inability to adhere to the facility's policies and communicate effectively contributed to the deficiencies in respiratory care for these residents.
Failure to Maintain Resident Dignity and Adequate Staffing
Penalty
Summary
The facility failed to maintain the dignity and pride of three residents, leading to feelings of embarrassment and frustration. One resident, who is cognitively intact and dependent on staff for activities of daily living, was left lying in her own feces for over 30 minutes after notifying a CNA of her condition. The CNA prioritized delivering breakfast trays over providing incontinence care, resulting in the resident feeling messy, stinky, and embarrassed. Another resident, who has moderate cognitive impairment and is dependent on staff for toileting, was left waiting for assistance for over an hour after activating her call light. The CNA on duty, who was the only one working the floor, instructed the resident to soil herself in bed, promising to clean her up later. This instruction was given due to a lack of available staff to assist with the resident's transfer to the toilet, causing the resident to feel humiliated and stripped of her dignity. A third resident, who is cognitively intact and serves as the President of the Resident Council, expressed concerns about the facility's staffing levels and the treatment of residents. The resident reported feeling belittled and treated like a child by some staff members, who displayed a lack of respect and professionalism. These incidents highlight the facility's failure to uphold its Resident Rights Policy, which guarantees residents a dignified existence and self-determination.
Staffing Deficiencies Lead to Resident Care Issues
Penalty
Summary
The facility failed to provide sufficient staff to meet the needs of residents, as evidenced by the experiences of four residents. One resident, who requires two staff members for transfers and assistance with toileting, reported that staff response to call lights could take 15-30 minutes, and on one occasion, a CNA had to perform tasks alone due to being the only staff member on the floor. This resident was left in a soiled state for over 30 minutes, causing distress and embarrassment. Another resident, who also requires assistance for ADLs, experienced a delay in staff response to a call light, resulting in a non-functioning oxygen concentrator going unchecked. The resident's daughter confirmed that call lights often went unanswered, and the facility was understaffed, particularly at night. A third resident, dependent on staff for toileting, was told by a CNA to soil herself in bed due to the lack of available staff to assist her. The resident's daughter, a licensed practical nurse, had to assist with care due to the staffing shortage. The facility's staffing records confirmed that only one CNA was working on a particular unit, contrary to the usual staffing of three CNAs. The Assistant Director of Nursing acknowledged the staffing issue and the difficulty in securing additional staff from an agency. The Director of Nursing was unavailable to assist during the staffing crisis, and the facility lacked a formal staffing policy, relying instead on state guidelines.
Unsafe Transfer of Resident Using Mechanical Lift
Penalty
Summary
The facility failed to provide a safe transfer for a resident, identified as R1, who was dependent on staff for activities of daily living and required the use of a full body mechanical lift device for transfers. R1, who had multiple medical conditions including COPD, respiratory failure, and morbid obesity, was transferred by a CNA without assistance, contrary to the facility's policy and the lift device's user manual, which recommend two assistants for safe operation. On a particular day, due to staffing shortages, a CNA was the only staff member available to assist R1, leading to the CNA performing the transfer alone. During the transfer, the CNA did not lock the wheelchair, and R1 was left free-swinging in the air without anyone holding onto them, which is against the recommended procedure. The facility's policy emphasizes resident safety, dignity, and comfort during transfers, but these were compromised in this instance. The user manual for the lift device also specifies that the wheelchair should be locked to prevent movement during the transfer, which was not adhered to, creating a potential hazard for R1.
Inadequate Incontinent Care and Resident Dignity Issues
Penalty
Summary
The facility failed to provide timely and complete incontinent care for two residents, R1 and R3, leading to deficiencies in maintaining their dignity and hygiene. R1, who has multiple medical conditions including COPD, respiratory failure, and bladder incontinence, was left in a soiled state for over 30 minutes after notifying a CNA of a bowel movement. The CNA, V13, failed to perform proper peri-care, did not change gloves when visibly soiled, and did not use a cleaning solution, leaving R1 feeling frustrated and embarrassed. R3, who suffers from conditions such as hypoglycemia, end-stage renal disease, and bladder incontinence, experienced a similar lack of timely care. R3's daughter reported that her mother was left waiting for over an hour after requesting assistance to use the restroom. The CNA, V9, instructed R3 to soil herself in bed due to a lack of available staff to assist with her transfer to the toilet, which was not handled appropriately and affected R3's dignity. The facility's failure to adhere to proper incontinent care procedures, as outlined in their Peri-Care Skills Checklist and Infection Prevention and Control Policy, contributed to these deficiencies. The staff did not follow the expected standards of practice for peri-care, including changing gloves and performing hand hygiene, which compromised the residents' dignity and hygiene.
Failure to Provide Continuous Oxygen Therapy
Penalty
Summary
The facility failed to provide continuous oxygen therapy as ordered for a resident (R2) who is oxygen-dependent due to chronic obstructive pulmonary disease (COPD) and acute respiratory failure. R2's care plan specified the need for continuous oxygen at 3 liters per minute via nasal cannula, yet observations revealed that the oxygen concentrator was off and beeping, indicating a malfunction. Despite the beeping, the certified nursing assistant (CNA) only turned the machine on to 2 liters per minute and informed the nurse, who did not check on the resident. The resident's oxygen was not consistently maintained at the prescribed level, as evidenced by the resident's daughter finding the oxygen set at only 1 liter per minute on a separate occasion. Interviews with staff revealed a lack of awareness and follow-through regarding the resident's oxygen needs. A CNA assumed the oxygen was on after a breathing treatment, and a registered nurse (RN) was unaware of the oxygen being off, despite the resident requiring continuous oxygen. The assistant director of nursing (ADON) confirmed the malfunctioning concentrator and replaced it, but the issue of incorrect oxygen settings persisted, as noted by the resident's daughter. The facility's oxygen administration policy requires verification of physician orders and proper setup and monitoring of oxygen equipment, which was not adhered to in this case. The nurse practitioner emphasized the critical nature of continuous oxygen for the resident's health, highlighting the potential risk to the resident's well-being due to the facility's failure to ensure proper oxygen administration as ordered by the physician.
Improper Food Storage and Labeling in Facility
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a manner that prevents potential contamination, affecting all 103 residents. During observations, multiple instances of improperly stored food were noted across various kitchen units and resident refrigerators. These included uncovered cheese slices, unlabeled and undated containers of rice, eggs, and other food items, as well as expired yogurt. The lack of proper labeling and dating was evident despite a laminated sign in the Resident Refrigerator instructing that all items should be clearly labeled with a name and date. Interviews and record reviews further confirmed the deficiency. The Dietary Manager acknowledged that all items placed in refrigerators and freezers should be labeled with a name and date. The facility's policy on labeling and dating foods was not adhered to, as evidenced by the numerous unlabeled and undated food items found during the survey. This oversight in food storage practices poses a risk of contamination and potential harm to the residents.
Failure to Submit PBJ Data for 4th Quarter 2024
Penalty
Summary
The facility failed to submit the required Payroll-Based Journal (PBJ) data for the 4th quarter of 2024, which has the potential to affect all 103 residents. The PBJ report for this period documented low weekend staffing, RN coverage for 8 consecutive hours per day, and licensed nurse coverage for 24 hours per day, resulting in a one-star staffing rating. The facility did not submit the PBJ data to CMS, as confirmed by the Administrator on January 14, 2025, who provided a notice from the State Agency documenting this failure. On January 17, 2025, the Administrator explained that the data was submitted to the corporate office in a timely manner but was not forwarded to CMS due to a new employee at the corporate office. Additionally, the facility lacked a policy regarding PBJ data submission.
Failure to Notify Family of Resident's Pneumonia Diagnosis
Penalty
Summary
The facility failed to notify a family representative of a significant illness and test results for a resident with moderate cognitive impairment. The resident's daughter, who is the family representative, filed a grievance expressing concern about not being informed of her mother's x-ray results, which indicated pneumonia. Despite the daughter's efforts to communicate with the Social Service Director about her mother's symptoms, she was not informed of the pneumonia diagnosis until she visited the facility and expressed her dissatisfaction. The nurse's progress notes confirmed that the daughter was unaware of the x-ray and its results, and the nurse informed her of the new orders related to the pneumonia diagnosis. The grievance filed by the daughter was founded, and the responsible LPN received a write-up and re-education on the importance of notifying families about significant changes in a resident's condition. The facility's policy on significant condition change and notification was not adhered to, leading to the deficiency.
Inappropriate Staff Cell Phone Use Violates Resident Rights
Penalty
Summary
The facility failed to protect the rights and dignity of two residents, as evidenced by the inappropriate use of personal cell phones by staff during care. One resident, who is cognitively intact and requires assistance due to various medical conditions including overactive bladder and diabetes, reported that CNAs frequently use earbuds and talk on their phones while providing care. This behavior led to confusion and irritation for the resident, as they often mistook the staff's phone conversations for communication directed at them. Another resident, also cognitively intact and dependent on staff for activities due to conditions such as myocardial infarction and hemiplegia, described similar issues with staff cell phone usage. The resident noted that a nurse would complete tasks and then watch her phone for extended periods, while CNAs with earbuds would inadvertently ignore the resident's questions. The issue of cell phone use was repeatedly raised in Resident Council Meetings and documented in grievance logs, yet the facility lacked a policy addressing cell phone use, despite having a policy on resident rights emphasizing respect and dignity.
Inadequate Incontinence Care and Infection Control Practices
Penalty
Summary
The facility failed to provide complete and timely incontinent care using proper techniques, which resulted in a urinary tract infection (UTI) for one of the residents. The report highlights that the facility did not perform hand hygiene and glove changes appropriately for three residents reviewed for incontinence care. Specifically, a certified nursing assistant (CNA) was observed performing peri-care on a resident without changing gloves or performing hand hygiene between different stages of the care process. This included using the same gloves to handle soiled linens and clean areas, which is against standard infection control practices. The report details the medical history and condition of the residents involved. One resident, who was cognitively intact and dependent on staff for toileting, was frequently incontinent of both bowel and bladder. This resident developed a UTI and was placed on antibiotic therapy. Another resident, also cognitively intact and totally dependent on staff for toileting, reported having to sit in soiled conditions for extended periods before being cleaned. The third resident, who was severely cognitively impaired, was observed receiving improper incontinence care, with the CNA using the same towel and gloves for different areas, leading to visible redness and irritation in the peri region. Interviews with staff and residents revealed that the facility's staff did not consistently follow proper hand hygiene and glove use protocols. Some staff members acknowledged the need for more training on these procedures, and the Resident Council President noted that staff did not check on residents every two hours as required. The facility's administrator confirmed the expectation for staff to perform timely and complete incontinence care, including proper hand hygiene and glove changes, but admitted that there was no specific policy on incontinent care, only a checklist.
Infection Control Deficiency in Glove Use and Hand Hygiene
Penalty
Summary
The facility failed to adhere to infection control practices and policies, specifically in the area of glove changing and hand hygiene during resident care. This deficiency was observed in the care of three residents, who were part of a sample of ten reviewed for infection control. The staff did not perform hand hygiene between glove changes, which is a critical step in preventing the transmission of infections. For Resident 7, a Certified Nursing Assistant (CNA) was observed performing peri-care without changing gloves or performing hand hygiene between tasks. The CNA used the same gloves to handle clean and soiled items, which is against the facility's infection control policy. Resident 7 has multiple health conditions, including urinary tract infection, and is dependent on staff for toileting and other activities of daily living. Similarly, Resident 6 and Resident 8 were also subjected to improper infection control practices. The CNAs involved did not change gloves or perform hand hygiene between different care tasks, such as cleaning soiled areas and handling clean linens. These actions were contrary to the facility's infection control and hand hygiene policies, which emphasize the importance of glove changes and hand hygiene to prevent the spread of infections.
Improper Transfer Techniques Result in Resident Injury and Fatality
Penalty
Summary
The report details a critical incident where a resident (R2) in a nursing home sustained bilateral femur fractures leading to her death due to improper transfer techniques by a Certified Nurse's Aide (V8). R2 had a history of Alzheimer's Disease, chronic pain syndrome, and vascular dementia with agitation, requiring substantial/maximal assistance for various activities including transfers. Despite the care plan indicating a 2-person assist for transfers, V8 attempted to transfer R2 alone, resulting in the fall and subsequent fractures. The incident occurred late in the evening, and despite efforts to assess and assist R2 promptly, the severity of the injuries was significant. The facility's documentation highlighted the lack of adherence to the care plan and proper transfer protocols, as V8 admitted to regularly transferring R2 alone despite her known limitations. The Licensed Practical Nurse (V9) also noted the absence of proper equipment like a gait belt or sit-to-stand device during the transfer. The report indicates that the facility's Fall Prevention Policy emphasized safety, assessment, fall prevention, and education for staff and residents, yet the failure to follow established protocols led to the tragic outcome for R2. The incident raised concerns about staff training, supervision, and adherence to care plans in ensuring resident safety during transfers. Medical professionals involved, including the ER Physician and Medical Director, noted the severity of R2's condition, with osteopenia complicating her ability to withstand surgical intervention for the fractures. The Medical Director attributed R2's death to the bilateral femur fractures.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 635 citations issued within 25 miles in the last 12 months — including the 26 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Belleville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nexus Pavilion At Belleville | 0.5 mi | ★★★★★ | 8 | 0 |
| Evercare Of Swansea | 0.7 mi | ★★★★★ | 8 | 1 |
| Bria Of Belleville | 0.9 mi | ★★★★★ | 13 | 0 |
| Helia Southbelt Healthcare | 1.3 mi | ★★★★★ | 18 | 0 |
| Evervella Of Swansea | 1.8 mi | ★★★★★ | 20 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.