Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Andrew Residence during CMS and state inspections, most recent first.
Failure to Timely Respond to Sexual Abuse Allegation: The facility did not immediately report, investigate, or protect residents after a family member reported unwanted sexual touching and advances by one resident toward another resident. The resident accused of the conduct had a history of poor sexual boundaries and unwanted physical contact, and additional residents later reported unwanted kissing, exposure, and inappropriate sexual comments from the same resident. Staff and leadership acknowledged the initial allegation was not promptly investigated or escalated, and the resident who reported the incident had a significant hx of sexual trauma and victimization.
Failure to Protect Residents from Sexual Abuse: A resident with a trauma history reported unwanted sexual advances by another resident, but the allegation was not promptly investigated or documented. The same resident had a history of sexually exploitive behavior, poor boundaries, and prior no-contact violations, and he later exposed himself and made inappropriate sexual comments to two other residents, including one with a trauma history and one with moderate cognitive impairment. Staff interviews showed the allegation was known earlier than it was acted on, and the resident’s behavior continued toward multiple residents.
Failure to Timely Report Alleged Resident Sexual Abuse: A resident with intact cognition and a significant MH history, including PTSD and prior sexual trauma, was allegedly subjected to unwanted sexual advances and non-consensual contact by another resident. A family member reported the incident to the SW, but the report was not documented or escalated to admin right away, and the SA report was delayed because staff believed they needed full details before reporting. Staff later acknowledged the allegation should have been investigated sooner and reported within the required timeframe.
The facility's system for reconciling non-narcotic, controlled medications relied on three-ring binders with loose paper, making it difficult for staff to detect if medication sheets or cards were removed. Staff and the DON confirmed that this method did not allow for timely identification of missing or diverted medications, as there was no secure or reliable way to track changes, and staff often depended on memory to notice discrepancies.
Two residents reported that a washing machine on the 5th floor was intermittently broken for months, with the most recent outage lasting over two weeks. Staff interviews confirmed ongoing issues, communication breakdowns, and incomplete repair documentation. Observations showed the machine contained standing dirty water and debris, and at times lacked an 'OUT OF ORDER' sign, resulting in an unsanitary environment.
Two residents had inaccurate MDS assessments, including one who was incorrectly documented as receiving insulin injections when only non-insulin diabetes medications were administered, and another who was coded with a dementia diagnosis not supported by the medical record. Nursing staff and the DON confirmed these errors after review.
A resident with COPD received oxygen therapy without documented baseline SpO2 or clear parameters for when to initiate or discontinue supplemental oxygen. The care plan and physician orders lacked specific guidance, and staff confirmed these omissions during interviews. Facility policy did not address the need for baseline SpO2 or individualized parameters.
A resident with schizoaffective disorder and a history of unsafe smoking behaviors sustained burns after using a cigarette to remove arm hair. Although staff implemented one-to-one supervision and escort for cigarette smoking, this intervention was not documented in the care plan, despite being communicated verbally and in progress notes. The care plan did not reflect the resident's current safety needs or the interventions being provided.
Two residents with wounds requiring bacitracin ointment did not have proper transcription or documentation of the medication in the MAR or EHR, despite its administration being recorded in progress notes. Facility staff confirmed that the standing order for bacitracin was not individually transcribed or documented with all required elements, leading to incomplete records and failure to follow professional standards for medication documentation.
A resident with an indwelling suprapubic catheter did not have Enhanced Barrier Precautions (EBPs) identified in the care plan, and staff failed to use required PPE, including gowns and gloves, during high-contact care activities such as shaving. A nursing assistant entered the room without hand hygiene or a gown, only donning gloves after entry, and completed shaving without following full EBP protocols. The DON confirmed that both gown and glove use were required for such care but were not implemented.
A resident with severe cognitive impairment was found with a broken bed rail due to the facility's failure to conduct regular inspections of hospital beds. Despite daily staff rounds, the broken condition was not reported. Interviews revealed no scheduled maintenance checks or logs, and the maintenance engineer was unaware of proper installation procedures.
The facility failed to ensure that the call light system was accessible from the floor in a multi-resident bathroom for three residents identified as fall risks. Observations showed that call lights were positioned too high for residents to reach if they fell. Interviews confirmed the residents' inability to access the call lights from the floor, despite their care plans emphasizing the need for immediate assistance. The DON acknowledged the issue but was uncertain about the necessity of floor-level access.
Failure to Timely Respond to Sexual Abuse Allegation
Penalty
Summary
The facility failed to immediately respond, investigate timely, and implement resident protections after an allegation of sexual abuse was reported involving two residents, and the failure was associated with subsequent sexual abuse involving two additional residents. The immediate jeopardy began when a family member reported that one resident had made unwanted sexual advances and unwanted touching toward another resident in that resident’s room. The social worker who received the report did not document the allegation, did not notify administrative staff at the time, and did not initiate a timely report to the State Agency because she believed she needed to obtain full details from the resident first. The resident who was the subject of the initial allegation had intact cognition and diagnoses including bipolar disorder, anxiety, PTSD, depression, and borderline personality disorder, with care plan and IPS documentation showing a history of sexual victimization and trafficking. The resident who was alleged to have engaged in the conduct had intact cognition and diagnoses including paranoid schizophrenia, with IPS documentation noting a history of unwanted physical contact and violations of no-contact orders, and that when symptomatic he misperceived communication from others. The record showed that the facility did not promptly interview the resident who reported the incident, did not timely investigate the allegation, and did not immediately put protections in place for other residents who were vulnerable to sexual abuse. During the same period, the resident alleged to have engaged in the conduct was involved in additional incidents with other residents. One resident reported unwanted kissing and advances, another resident reported inappropriate sexual conversation and exposure, and another resident reported unwanted kissing and difficulty maintaining boundaries. The records showed repeated incidents of the resident entering other residents’ rooms or floors, exposing himself, and engaging in unwanted sexual behavior before restrictions and monitoring were documented. The facility’s own staff and leadership acknowledged that the initial allegation should have been investigated sooner and that the incident was not relayed appropriately at the time it was first reported.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse when one resident with intact cognition and a history of bipolar disorder, anxiety, PTSD, depression, and borderline personality disorder reported that another resident entered her room and made sexual advances toward her. Her care plan and IPS assessment documented a history of sexual trauma, victimization, and trafficking, and her family member reported the incident to the facility after the resident did not want it reported. The social worker acknowledged she learned of the allegation but did not document the information, and no investigation or protections were started or considered until several days later. The resident accused of the behavior also had intact cognition and a diagnosis of paranoid schizophrenia, along with a history of sexually exploitive behavior, unwanted physical contact, and violating no-contact orders. His IPS assessment noted that when symptomatic he misperceived communication from others, but the assessment lacked a care plan for sexual exploitation or vulnerability related to sexual health and did not address behaviors when symptomatic. His care plan initially restricted him from some areas, but the report states it lacked interventions to protect other residents after staff were informed of the behavior. Additional incidents involved two other residents. One resident with a history of sexual victimization reported that the same resident kissed her on the cheek without consent, touched her, and exposed himself to her, leaving her uncomfortable and afraid. Another resident with moderate cognitive impairment and a history of physical and sexual abuse reported that he embraced her in her doorway, kissed her on the cheek against her wishes, and later exposed himself and made inappropriate sexual comments to her. Staff notes and interviews showed repeated unwanted sexual contact and exposure involving the same resident, while the facility did not immediately investigate or implement protections after the first report was received.
Failure to Timely Report Alleged Resident Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident sexual abuse immediately, within 2 hours, to the State Agency after a family member reported that one resident made unwanted sexual advances toward another resident. The allegation involved a resident with intact cognition and diagnoses including bipolar disorder, anxiety, PTSD, depression, and borderline personality disorder, and the resident had a documented history of sexual victimization, sexual trauma, and being sexually trafficked. The resident’s care plan also identified that the resident exhibited behaviors that allowed others to manipulate, exploit, victimize, and bully her. The family member reported that the other resident entered the resident’s room, exposed himself, pushed his pelvis against the resident’s hip, and made romantic overtures. The facility’s social worker acknowledged she became aware of the report when the family member called, but she did not document the report, did not document her attempts to contact the resident, and did not notify administrative staff at that time. She stated she believed she needed full details from the resident before making a report, and the program director stated the facility did not receive the report until later and that no one followed up promptly. The resident later stated the other resident went further than he should have, would not leave her room, and she had to yell at him and threaten to pull the alert cord to get help. Staff interviews reflected that the incident should have been investigated sooner and that the State report was not filed until after the facility obtained more information. The report also described a separate resident-to-resident interaction involving kissing and unwanted contact with another resident, with staff stating they intervened immediately and that it was not reportable.
Inadequate Medication Reconciliation System for Non-Narcotic Controlled Medications
Penalty
Summary
The facility failed to ensure an adequate system for medication reconciliation to timely identify loss or diversion of non-narcotic, controlled medications across all medication carts reviewed. Observations and interviews revealed that non-narcotic, controlled medications were stored in permanently affixed lock boxes within locked medication carts, and staff reconciled these medications every shift using a three-ring binder with loose, three-hole punched paper. Staff members confirmed that the reconciliation process involved comparing the count of medications in the locked box to the corresponding sheet in the binder, and referencing the medication administration record if discrepancies were noted. However, staff also acknowledged that the use of loose paper in a three-ring binder made it difficult to detect if a medication sheet and the corresponding medication card were removed, as there was no way to tell when a sheet was missing until the next administration of the medication. The director of nursing (DON) and multiple staff members confirmed that the current practice did not provide a reliable method for timely identification of missing or diverted non-narcotic, controlled medications. The facility's policy required shift change counts and documentation on a controlled drug record and a C-drug Count Acknowledgement Form, but did not specify the use of a bound book or other secure method for recordkeeping. Staff expressed uncertainty about how they would notice if documentation or medication was removed, relying instead on memory or familiarity with the medications. This system limitation was observed on all floors reviewed, and the DON acknowledged the inadequacy of the current practice for tracking and reconciling non-narcotic, controlled medications.
Failure to Maintain Functional and Sanitary Laundry Equipment
Penalty
Summary
The facility failed to ensure that equipment was in proper working order and to maintain a sanitary environment in the 5th floor laundry room. Two residents, both cognitively intact and independent with activities of daily living, reported that one of the two washing machines had been intermittently broken for several months, with the most recent outage lasting over two weeks. Multiple staff interviews confirmed ongoing issues with the washing machine, including repeated breakdowns, delays in repairs, and a lack of awareness about the presence of standing water inside the machine. Staff described a process for reporting repairs through TELS tickets, but there was evidence of communication breakdowns between residents, staff, and maintenance, as well as incomplete documentation of repair requests. Observations over several days revealed that the broken washing machine contained dark grey standing water with floating debris and a film layer, and at times lacked an "OUT OF ORDER" sign. Housekeeping and maintenance staff confirmed the unsanitary condition and the extended period the machine had been out of service. Maintenance staff were at times unaware of the duration of the breakdown or the presence of standing water. Record review showed only one documented TELS report for the issue, despite staff claims of multiple reports, and a complete TELS report was not provided upon request.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for two residents. For one resident, the quarterly MDS indicated the resident was cognitively intact, had a diagnosis of diabetes, and received seven days of insulin injections. However, review of the medication administration record (MAR) did not show any insulin injections administered during the observation period. Further investigation revealed that the resident was prescribed Metformin, an oral diabetes medication, and Victoza, a non-insulin injectable medication. Both the registered nurse and the Director of Nursing confirmed that Victoza is not an insulin and should not have been recorded as such on the MDS. For another resident, the quarterly MDS documented an active diagnosis of non-Alzheimer's dementia. Upon review of the resident's medical record, there was no documentation to support a diagnosis of non-Alzheimer's dementia. The Director of Nursing confirmed that this was an error in the MDS coding, as the diagnosis was not present in the medical record. These inaccuracies in the MDS assessments were identified through interviews and record reviews.
Failure to Establish Baseline SpO2 and Oxygen Therapy Parameters for Resident with COPD
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with chronic obstructive pulmonary disease (COPD) by not identifying a baseline SpO2 (blood oxygen level) and not establishing clear parameters for the use or discontinuation of supplemental oxygen therapy. The resident's care plan and physician orders included the use of an oxygen concentrator at 4 liters per minute via nasal cannula as needed, but did not specify when to initiate or discontinue oxygen, nor did they document the resident's baseline SpO2. The Treatment Administration Record showed SpO2 levels ranging from 91% to 99%, but did not indicate whether supplemental oxygen was in use at the time of these readings. Interviews with nursing staff and the director of nursing confirmed the absence of parameters and baseline SpO2 in the resident's orders and care plan. The director of nursing acknowledged that such information is expected, especially for residents with COPD, due to the risks associated with over-oxygenation. The facility's existing oxygen concentrator policy did not address the identification of baseline SpO2 or provide guidance on parameters for use based on resident-specific risk factors.
Failure to Update Care Plan with Smoking-Related Safety Intervention
Penalty
Summary
The facility failed to revise the care plan for a resident with schizoaffective disorder and a history of unsafe smoking behaviors, specifically not including a smoking-related safety intervention after the resident sustained burns from using a lit cigarette to remove arm hair. The resident was known to have cognitive impairments affecting judgment and had a documented history of self-inflicted burns related to smoking, with previous assessments identifying him as vulnerable and requiring specific interventions, such as the use of flameless lighters and staff assistance with hair removal. Despite these known risks and a recent incident where the resident burned himself with a cigarette, the care plan was not updated to reflect the newly implemented intervention of one-to-one staff escort and supervision when the resident smoked cigarettes. Multiple staff interviews confirmed that the resident required one-to-one supervision when smoking cigarettes, a measure that was verbally communicated and documented in progress notes and incident reports, but not formally included in the resident's care plan. Staff relied on verbal communication, staff logs, and program sheets to know about the intervention, but the care plan, which is the primary document for guiding resident care, did not reflect this critical safety measure. The omission was acknowledged by several staff members, including the program director, director of nursing, and director of clinical services, who all stated that the intervention should have been included in the care plan for consistency and continuity of care. Facility policies required that residents assessed as vulnerable for unsafe smoking behaviors have a vulnerability care plan with outlined interventions, and that care plans be reviewed and revised as needed. However, the implemented intervention of one-to-one staff escort for cigarette smoking was not documented in the care plan, despite being in practice. This failure to update the care plan meant that the formal documentation did not accurately reflect the resident's current needs and the interventions being provided to ensure his safety.
Failure to Properly Document and Transcribe Standing Order Medication Administration
Penalty
Summary
The facility failed to ensure that professional standards of practice for documentation were followed during the transcription and administration of a standing order medication, specifically bacitracin ointment, for two residents with wounds. The standing order for bacitracin required that it be transcribed into the resident's medication administration record (MAR) with all necessary details, including the prescribing practitioner's name, medication name, dosage, route, frequency, duration, and indication for use. However, for both residents, the administration of bacitracin was documented in progress notes but not properly transcribed or documented in the MAR or electronic health record (EHR) as required by facility policy and professional standards. For the first resident, who had a history of schizoaffective disorder and sustained multiple self-inflicted burns and other minor wounds, bacitracin was applied on several occasions as documented in progress notes. Despite this, there was no corresponding order or documentation in the MAR or EHR specifying the use of bacitracin, nor were the required elements of a complete medication order present. Nursing staff confirmed that the standing order for bacitracin should have been transcribed into the MAR and EHR, but this was not done. The facility's process relied on a general standing order in the physician orders, without individual transcription upon use, which led to incomplete documentation and lack of clarity regarding the administration of the medication. For the second resident, who sustained a burn to the finger, bacitracin was also applied and documented in progress notes prior to the transcription of a wound care order into the MAR. The MAR did not include all required elements of the bacitracin order, and the wound care order did not specify the seven-day limit as required by the standing order. Interviews with nursing staff and the DON revealed that the facility practice was not to transcribe individual standing orders into the MAR or EHR unless specifically utilized, and that documentation of administration was often limited to progress notes rather than the MAR. This practice resulted in incomplete and inconsistent documentation of medication administration, failing to meet professional standards and facility policy.
Failure to Use Required PPE During High-Contact Care for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures by not ensuring staff used required personal protective equipment (PPE) during high-contact care for a resident with an indwelling suprapubic catheter. The resident had multiple urinary diagnoses, including bladder disorder, urethral stricture, benign prostatic hyperplasia, bladder neck obstruction, and overactive bladder, and required regular shaving of the head and body as part of activities of daily living. The care plan for the resident did not identify the need for Enhanced Barrier Precautions (EBPs) despite the presence of an indwelling catheter, and signage on the resident's door indicated the need for PPE during high-contact care activities. During observation, a nursing assistant entered the resident's room without performing hand hygiene or donning a gown, and only put on gloves after entering the room. The assistant proceeded to shave the resident's inner thigh, pubic area, buttocks, and arms, then exited the room carrying soiled supplies in gloved hands without performing hand hygiene. The assistant stated she had not been instructed to use a gown for this care activity and only used gloves. The director of nursing confirmed that EBPs, including gown and glove use, were required for residents with indwelling devices during high-contact care, and that these precautions should have been included in the care plan.
Failure to Conduct Regular Bed Inspections
Penalty
Summary
The facility failed to conduct regular inspections of hospital bed frames, mattresses, and bed rails, leading to a deficiency involving a resident with a broken bed rail. The resident, who had severe cognitive impairment and was independent in activities of daily living, was observed with a broken pivoting assist device (PAD) on their bed. The right PAD was not aligned with the bed frame and was touching the floor, indicating it was broken. Despite daily staff rounds, the broken condition of the PAD was not reported or addressed until it was observed by surveyors. Interviews with facility staff revealed a lack of scheduled maintenance checks for the resident's bed, and no maintenance logs were kept. The maintenance engineer admitted to not reviewing the manual for proper installation and was unaware of the correct procedures. The facility's Director of Nursing confirmed that the bed had been in use since the care plan intervention date, but no maintenance policy or inspection logs were provided. The owner's manual for the bed recommended periodic inspections, which were not conducted, leading to the deficiency.
Inaccessible Call Light System in Multi-Resident Bathroom
Penalty
Summary
The facility failed to ensure that the resident call light system was accessible from the bathroom floor in a multi-resident bathroom for three residents. Observations revealed that the call lights were positioned on the walls with cords that were not reachable from the floor, being approximately two to three feet above it. Interviews with the residents confirmed that they were unable to reach the call lights if they fell while using the toilet or shower, despite having a history of falls and being identified as fall risks. The care plans for these residents emphasized the importance of using the emergency call-light system for immediate assistance, yet the physical setup did not support this need. The Director of Nursing acknowledged that the call lights might not be within reach if the residents were on the floor, but expressed uncertainty about the necessity of floor-level access due to the residents' ambulatory status. The facility's policy on the emergency monitoring system indicated that pull station transmitters should be located in resident rooms, bathrooms, and other common areas, with all activations requiring a timely response from staff. However, the current setup in the multi-resident bathroom did not align with this policy, as it did not allow residents to access the call system from the floor, potentially delaying urgent assistance.
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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 Minneapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Benedictine Health Center Of Minneapolis | 0.5 mi | ★★★★★ | 8 | 0 |
| The Estates At Chateau Llc | 0.9 mi | ★★★★★ | 14 | 1 |
| Fairview University Trans Serv | 1.1 mi | ★★★★★ | 0 | 0 |
| Southside Care Center | 1.8 mi | ★★★★★ | 28 | 1 |
| Catholic Eldercare On Main | 2 mi | ★★★★★ | 16 | 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.