Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Augustana Chapel View Care Center during CMS and state inspections, most recent first.
A resident with significant cardiopulmonary conditions and an NP order for continuous O2 at 2 L/min to maintain SpO2 >90% was sent to an off-site wound care appointment without supplemental O2. Nursing documentation showed recent low-normal SpO2 readings on 1–2.5 L O2, and a progress note recorded SpO2 of 93% on 1 L O2 before departure. A CNA, who was unaware the O2 order had been changed to continuous and reported issues with a hissing portable tank and resident refusal while getting ready, assisted the resident and allowed her to leave without O2. At the clinic, the resident was found lethargic with SpO2 of 70% on room air and was transferred to the ED, where she was documented as hypoxic, tachycardic, and experiencing acute on chronic respiratory failure, with hospital notes indicating that lack of O2 may have precipitated the event.
A resident’s wheelchair remained visibly soiled over multiple observations, with peeling tape and dried white and brown crusted पदार्थ on the footrest, calf rest, and arm rests. Two residents with tube feeding also had IV poles with dried white substance covering the legs of the poles over several days. Staff gave conflicting accounts about who was responsible for cleaning the wheelchair and IV poles, and the facility policy called for cleaning visibly soiled equipment and weekly disinfection of IV equipment.
Survey Results Binder Missing Complaint Findings: The facility failed to keep the Survey Results binder complete for review by residents, visitors, and staff. The binder contained recent recertification survey results but lacked multiple 2567s for complaint investigations, revisits, state licensure visits, and LSC surveys. The administrator stated he was responsible for adding the 2567 information, and the facility policy required the most recent survey results and any POC to be available for resident review.
During an Influenza A outbreak, the facility did not consistently monitor or screen residents for respiratory symptoms, nor did it promptly implement or document transmission-based precautions for symptomatic individuals. Several residents with complex medical conditions developed influenza, with some requiring hospitalization. Staff were observed entering rooms on contact and droplet precautions without proper PPE, and infection control records were incomplete, contributing to the spread of the virus.
Two residents with complex medical histories experienced changes in condition, including confusion, respiratory symptoms, and signs of infection, but did not receive timely or comprehensive assessment and monitoring as required by facility policy. Despite staff and provider expectations for frequent monitoring and documentation, records lacked evidence of ongoing vital sign checks, respiratory assessments, or prompt provider notification. Both residents were subsequently hospitalized with influenza A and related complications.
A resident with a history of stroke and aneurysm received ibuprofen 66 times on a scheduled basis due to a transcription error, instead of as needed per the physician's order. The error occurred when the order was incorrectly entered into the EHR and subsequently administered by staff according to the MAR. The facility did not promptly notify the physician or family, nor did it document whether the resident experienced any adverse effects.
A resident with multiple complex medical conditions received an excessive dose of hydromorphone after staff administered 4 mg based on a medication card label that conflicted with the MAR. Confusion arose from two different hospital discharge orders and pharmacy deliveries, and staff did not consistently verify the most current physician order or properly mark outdated medication cards. The resident experienced respiratory depression and required emergency intervention for suspected opioid overdose.
The facility did not ensure timely completion of physician-ordered laboratory tests for three residents with acute medical needs. In each case, STAT or urgent lab orders were delayed due to issues such as lack of follow-up with the lab, insufficient supply monitoring, and unclear procedures for specimen collection and pick-up. Providers were not notified of delays, and facility policies for urgent lab processing and supply management were not consistently followed.
A resident tested positive for influenza A, but staff failed to notify the ordering practitioner of the abnormal result. The nurse manager documented the results as negative and was unaware of the positive finding, and both the DON and nurse practitioner confirmed they were not informed. Facility policy required timely notification of abnormal lab results, which did not occur in this case.
A resident's EHR was found to be incomplete, missing a provider visit note and key hospital documents following a hospitalization. Staff interviews confirmed that these documents were not uploaded as required, and there was no clear process for tracking non-routine provider notes, resulting in an inaccurate and incomplete medical record.
Three residents with varying cognitive abilities and respiratory conditions were left unattended during nebulizer treatments after staff set up the equipment, without proper assessment of their ability to safely manage the treatment independently. Despite their preference not to self-administer medications, no further evaluation was conducted to ensure they could complete the treatment safely when left alone, contrary to facility policy.
A resident with moderate cognitive impairment and mobility issues had grab bars installed without comprehensive assessment or documentation of risks and benefits. The facility failed to provide education or obtain informed consent, and staff interviews revealed inconsistencies in the assessment and installation process.
The facility failed to ensure proper use of enhanced barrier precautions (EBP) and personal protective equipment (PPE) during high-contact care for two residents. Staff did not consistently wear gowns and gloves as required, despite signage and training. This non-compliance occurred during care activities for residents with significant medical needs, including catheter care and wound management.
The facility failed to document advance directives for several residents, including those with severe cognitive impairments. Despite care conferences, there was no evidence of offering advance directive planning. The DON admitted reliance on hospital discharge papers for code status, and no policy was provided upon request.
The facility failed to ensure that all licensed staff were properly trained and certified in BLS/CPR, with 18 out of 62 staff lacking valid certifications. Interviews revealed that while BLS classes were offered, there was no system to ensure current certifications, and no disciplinary actions were enforced for non-compliance. The facility also lacked a formal audit and did not provide a BLS/CPR policy.
The facility failed to honor a resident's bathing preferences, leading to inconsistent provision of bed baths and lack of hair washing for ten weeks. Despite the resident's documented preference for bed baths due to medical conditions, staff did not consistently follow up or document these preferences, resulting in a deficiency in resident self-determination and choice.
The facility failed to revise a comprehensive care plan for a resident with multiple severe injuries, resulting in the omission of critical medical instructions from the care plan and electronic health record. The Director of Nursing acknowledged the oversight and breach in protocol, which could potentially lead to harm.
A resident with serious medical conditions did not receive their prescribed total parenteral nutrition (TPN) and lipids on multiple occasions due to unavailability. The facility failed to ensure an adequate supply and timely administration of these medications, as confirmed by the medication administration record and interviews with staff.
Failure to Provide Ordered Continuous Oxygen During Off-Site Appointment
Penalty
Summary
The facility failed to follow practitioner orders for continuous oxygen (O2) therapy for a resident with multiple cardiopulmonary comorbidities when sending her to an off-site wound care appointment. The resident had diagnoses including morbid obesity with alveolar hypoventilation, hypertensive kidney disease, lymphedema, atrial fibrillation, venous insufficiency, and hypoxemia, and her care plan and recent NP orders directed continuous O2 at 2 L/min via nasal cannula to maintain O2 saturation above 90%, with MAR instructions to check O2 saturation every four hours and titrate O2 between 1–6 L/min if saturation fell below 90%. On the morning of the incident, documented O2 saturations ranged from 90–93% on 1–2.5 L O2, and a progress note recorded that the resident was 93% on 1 L O2 via nasal cannula before leaving for her wound appointment. Despite these orders, the resident was sent to the wound clinic without supplemental O2. A nursing assistant assisted the resident to get ready and later reported that the portable O2 tank was broken and making a hissing noise, and that the resident refused O2 while getting ready; the nursing assistant also stated she had not been informed that the O2 order had been changed to continuous use. The nurse manager and ADON confirmed that the resident left for the appointment without O2, and the NP stated she expected the resident to be sent with supplemental O2 given the new continuous O2 order. At the wound clinic, staff found the resident lethargic, with difficulty keeping her eyes open and an O2 saturation of 70% on room air, and she was transferred to the ED, where she was noted to be short of breath, somewhat confused, tachycardic, and hypoxic, with hospital documentation indicating acute on chronic respiratory failure with hypoxia and hypercapnia and noting that lack of O2 may have precipitated the acute event.
Soiled Resident Wheelchair and IV Poles
Penalty
Summary
Resident equipment was not maintained in a clean and sanitary condition. R4’s annual MDS indicated cognitive intactness, extensive assistance with cares, diagnoses including hemiplegia, diabetes, spondylosis, and osteoarthritis, and use of a wheelchair for locomotion. R4’s care plan identified assistance needs for wheelchair mobility due to impaired mobility and left-sided hemiplegia. During repeated observations, R4’s wheelchair remained soiled, with dycem and tape peeling on the footrest and calf rest, an unidentified white and brown crusty substance on the taped areas, and a small piece of paper taped to the arm rest with dried brown substance at the tape edges. The wheelchair was observed in the same condition over multiple days, and staff gave conflicting accounts about who was responsible for cleaning wheelchairs and when they were cleaned. R40 and R98 also had tube feeding equipment that was not kept clean. R40’s significant change MDS showed moderate cognitive impairment and dependence on staff, with diagnoses including dysphagia, gastrostomy, diabetes, hypertension, and stroke. R98’s quarterly MDS showed severe cognitive impairment and total dependence on staff, with diagnoses including Parkinson’s disease, traumatic brain injury, quadriplegia, gastrostomy, and dysphagia. In both residents’ rooms, IV poles attached to tube feeding pumps were observed with an unidentified white, dried substance covering all five legs of the poles. The substance remained present on repeated observations over several days. Staff interviews showed inconsistent responsibility for cleaning the IV poles and feeding pumps. NA staff stated nurses cleaned the poles and pumps, RN-A stated they were cleaned on day shift, RN-B stated housekeeping cleaned IV poles, and housekeeping staff stated IV pole cleaning was not on housekeeping’s list. The ADON stated nurses should wipe down IV poles when they were observed to be dirty and described the poles as gross, while the facility policy stated IV equipment such as IV poles should be disinfected weekly or more often if visibly soiled, but no schedule was available for IV pole cleaning.
Survey Results Binder Missing Complaint Investigation Findings
Penalty
Summary
The facility failed to ensure results of complaint investigations were available for review in the survey results binder located next to the reception desk at the entrance of the building. During observation, the binder labeled Survey Results contained recertification survey results from the past three recertification surveys, but it did not include any of the 2567s for complaint investigations. The missing 2567s were identified for complaint investigations, revisits, state licensure visits, and Life Safety Code surveys completed after the recertification survey of 11/24/25, including 1/2/25, 1/8/25, 1/15/25, 1/16/25, 3/7/25, 4/2/25, 6/22/25, and 7/9/25. During interview, the administrator stated he was responsible for placing the 2567 information into the survey binder and said it was important for the binder to be up to date and accurate so the information would be available to residents, visitors, and staff who wished to review the survey results. The facility policy, Posting of Survey Results, reviewed 11/20/25, stated the facility was to make results of the most recent survey and any plans of correction available to all residents, and defined those results as the statements of deficiencies from the 2567 and any subsequent extended surveys, as well as any deficiencies resulting from subsequent complaint investigations.
Failure to Implement Effective Infection Control During Influenza A Outbreak
Penalty
Summary
The facility failed to implement effective infection prevention and control strategies for respiratory protection, specifically in response to an outbreak of Influenza A. There was a lack of ongoing monitoring and screening of residents with respiratory symptoms, and transmission-based precautions (TBP) were not consistently or promptly implemented for symptomatic residents. Documentation revealed that TBP were often delayed, not initiated at symptom onset, or removed without comprehensive assessment and monitoring for symptom resolution. In several cases, residents with symptoms were not placed on appropriate precautions until days after symptom onset or after laboratory confirmation, and there was no consistent documentation of respiratory assessments or the rationale for removal of precautions. Multiple residents with complex medical histories, including conditions such as hemiplegia, diabetes, COPD, morbid obesity, and immunodeficiency, developed symptoms consistent with influenza and subsequently tested positive. Several residents required hospitalization due to complications. The facility's infection control records did not reflect timely or comprehensive surveillance, and there was no evidence of active respiratory symptom screening for residents who were exposed or symptomatic. Staff interviews confirmed that assessments were not always documented, and infection tracking logs were incomplete, missing key information such as the start and end dates of TBP and not including all symptomatic residents. Direct observations revealed staff entering rooms of residents on contact and droplet precautions without donning the required personal protective equipment (PPE) as indicated by signage. Staff demonstrated inconsistent understanding and adherence to infection control protocols, with some staff only wearing masks when full PPE was required. Housekeeping staff were also observed failing to follow proper PPE and hand hygiene protocols when cleaning rooms of residents on precautions. These failures contributed to the spread of Influenza A within the facility, resulting in an outbreak affecting multiple residents and leading to an immediate jeopardy situation due to the risk of further transmission.
Failure to Monitor and Assess Residents with Acute Illnesses Resulting in Hospitalization
Penalty
Summary
The facility failed to comprehensively assess and appropriately monitor two residents with acute illnesses, including influenza, which resulted in hospitalization. For one resident with a history of COPD, CHF, diabetes, and chronic respiratory failure, staff identified a change in condition marked by confusion, poor appetite, and a cough. Although the provider was notified and laboratory tests were ordered, the resident's records lacked documentation of ongoing assessment and monitoring of vital signs, respiratory status, or infection after the change in condition was noted. There was no evidence of additional monitoring or assessment between the time the change was identified and the resident's transfer to the hospital, despite staff interviews indicating that more frequent monitoring should have occurred. The resident was later hospitalized with diagnoses including influenza A, hypoxia, sepsis, and acute respiratory failure. Another resident with CHF, dementia, and an indwelling catheter experienced a change in condition characterized by foul-smelling urine and altered mental status. The provider was notified via a written message rather than an immediate call, and laboratory tests for infection and influenza were ordered. The resident's records did not show evidence of ongoing assessment or monitoring of vital signs, respiratory status, or urinary symptoms after the change in condition. Despite orders for daily monitoring and documentation, there were no corresponding progress notes or evidence of additional monitoring. The resident was later hospitalized with influenza A, sepsis, and a high fever. Interviews with nursing staff and the DON confirmed that the expected standard of care was not met, as there was a lack of timely and thorough assessment and monitoring following the residents' changes in condition. Facility policies required prompt provider notification and active surveillance for illness, especially during an influenza outbreak, but these were not followed. The records lacked documentation of the required assessments and monitoring, and there was a delay in provider notification and treatment for both residents.
Medication Order Transcription Error Resulting in Incorrect Ibuprofen Administration
Penalty
Summary
The facility failed to ensure accurate transcription of physician orders for a resident with a history of stroke and aneurysm, resulting in a medication error. The resident was prescribed ibuprofen 400 mg every 6 hours as needed (PRN) for pain or fever, but the order was incorrectly transcribed into the electronic health record (EHR) as a scheduled dose every 6 hours. As a result, the resident received ibuprofen 66 times over a period of approximately two weeks, rather than only as needed. The medication administration record (MAR) reflected the incorrect scheduled dosing, and staff administered the medication according to the MAR. The error was identified as a human transcription error, with the health unit coordinator entering the order, the charge nurse checking it, and nursing staff administering the medication based on the MAR. The facility's medication error report noted that the physician and family were not notified in a timely manner, and the resident's record did not document whether the resident experienced any untoward effects from the medication. Interviews with staff confirmed the process and the error, and the facility's policy required prompt reporting, observation for effects, and notification of the physician and family, which was not fully followed in this case.
Significant Medication Error Due to Conflicting Orders and Inadequate Verification
Penalty
Summary
A resident with a history of fractured left femur, status post hemiarthroplasty, acute respiratory failure with hypoxia, and acute bronchitis due to RSV was admitted to the facility with two different Dilaudid (hydromorphone) orders from the hospital. The pharmacy received both orders, leading to confusion and the delivery of medication cards with conflicting dosing instructions. The medication administration record (MAR) and the medication card label did not match, and staff were instructed to follow the MAR if discrepancies arose. However, the medication card with the incorrect dose was not properly marked or removed, and staff did not consistently verify the most current physician order before administration. On the morning in question, an LPN administered 4 mg of hydromorphone to the resident for severe pain, after verifying the medication card label with the MAR. Shortly after, the resident was found to have abnormal, labored breathing and was difficult to arouse. Emergency medical services were called, and the resident was transferred to the hospital, where an opioid overdose was suspected and treated with Narcan. The facility's policies required staff to administer medications as prescribed, verify the six rights of medication administration, and observe and document the resident's response to PRN medications, but these procedures were not fully followed in this case. Interviews with staff revealed that there was confusion regarding which order to follow, and the process for reconciling discrepancies between the MAR and medication card was not consistently implemented. The medication card with the outdated order was not immediately marked to prevent administration, and staff did not always verify the most current physician order when discrepancies were identified. This series of actions and inactions resulted in the resident receiving a significant medication error, specifically an excessive dose of hydromorphone, leading to an adverse clinical event.
Failure to Obtain Timely Laboratory Services for Physician-Ordered Tests
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory studies were obtained in a timely manner for three residents with acute medical needs. For one resident with multiple diagnoses including diabetes, hyperkalemia, and heart failure, a STAT order for CBC and BMP was placed following a change in condition. While some specimens were collected promptly, the blood draws for CBC and BMP were delayed until the following day, despite facility policy and staff expectations that STAT labs be collected within two hours. There was no evidence of additional follow-up with the laboratory or notification to the provider regarding the delay, and the provider only became aware of the delay the next morning when the resident's condition had further declined, resulting in a hospital transfer. Another resident with a history of heart failure, hematuria, and urinary tract infection had laboratory orders for respiratory viruses and urinalysis following an acute episode of confusion and foul-smelling urine. The required swabs were not collected on the day of the order due to a lack of supplies, and the tests were performed the following day. The provider was not notified of the delay, nor of the positive influenza result, contrary to facility policy and provider expectations. Interviews revealed that the system for monitoring and ordering lab supplies relied on nurses to notify health unit coordinators when supplies were low, and there was no routine monitoring in place. A third resident admitted for rehabilitation after hip surgery developed fever and cough, prompting orders for respiratory virus testing. While a COVID-19 test was collected and processed, there was no documentation of results for influenza and RSV, and staff interviews indicated uncertainty about specimen storage and lab pick-up procedures. The laboratory confirmed that STAT orders required direct notification from the facility, which did not occur. Facility policies required immediate action for urgent lab orders and a system for maintaining adequate supplies and timely specimen transport, but these procedures were not consistently followed.
Failure to Notify Practitioner of Abnormal Lab Result
Penalty
Summary
A deficiency occurred when facility staff failed to promptly notify the ordering practitioner of an abnormal laboratory result for a resident who was tested for influenza A, RSV, and COVID-19 following an acute visit for a new problem. The laboratory swab was collected and resulted in a positive influenza A finding, which was marked as abnormal. However, the nurse manager documented in a late entry note that the lab results were negative and later admitted to being unaware of the positive result. The only evidence of the positive result was a scanned copy of the faxed lab report, and there was no documentation confirming that the nurse manager had notified the nurse practitioner of the abnormal finding. Interviews with the DON and the nurse practitioner confirmed that neither was aware of the positive influenza A result until informed by surveyors. The DON stated that she expected the provider to have been notified, and the nurse practitioner indicated she would have treated the resident for influenza A had she been informed. The facility's policies required timely notification of abnormal lab results to the attending physician or designee, but this was not followed in this instance.
Incomplete Medical Record Documentation for Hospitalized Resident
Penalty
Summary
The facility failed to maintain a complete, accurately documented, and readily accessible medical record for a resident who was reviewed for documentation. The resident was admitted to the facility and subsequently sent to the hospital due to confusion, weakness, and distress. Upon return from the hospital, the resident's electronic health record (EHR) was missing key documents, including a provider visit note from the day the resident was sent to the hospital, as well as the hospital discharge summary and physician history and physical (H&P) from the hospitalization period. Interviews with facility staff revealed that while there was a process for uploading provider notes and hospital documents into the EHR, there was a lack of tracking for non-routine provider visits and some hospital documents. The health unit coordinator confirmed that the missing documents were not present in the EHR and should have been uploaded, and the director of nursing acknowledged that the resident's medical record was incomplete and not accurate at the time of review. Facility policy required that such documentation be included in the resident's legal health record.
Failure to Assess Residents' Ability to Self-Administer Nebulizer Treatments
Penalty
Summary
The facility failed to complete thorough self-administration assessments for three residents who did not wish to self-administer their medications but were left unattended during nebulizer treatments. For each of these residents, staff set up the nebulizer treatment, applied the mask, and turned on the machine, then left the room while the treatment was ongoing. No further assessment was conducted to ensure these residents were competent to manage the nebulizer, such as removing the mask or turning off the machine when finished. Observations confirmed that residents were left alone with the nebulizer running, and interviews revealed that some residents did not recall who operated the machine or were not involved in the process beyond receiving assistance from staff. The residents involved had varying levels of cognitive function and medical conditions, including multiple sclerosis, asthma, surgical aftercare, acute respiratory failure, and chronic obstructive pulmonary disease. Despite their preferences not to self-administer medications, the facility did not perform additional assessments to determine their ability to safely complete nebulizer treatments independently when left unattended. Staff interviews indicated inconsistent understanding of the requirements for self-administration assessments and supervision during nebulizer treatments, and the facility's policy required an observation to be completed if a resident was to self-administer medications, including nebulized treatments.
Failure to Assess and Document Risks and Benefits of Grab Bars
Penalty
Summary
The facility failed to comprehensively assess and discuss the risks and benefits prior to the installation of grab bars for a resident identified as R194. The resident had moderate cognitive impairment and required assistance with bed mobility. Despite these needs, the facility did not document a thorough assessment of the resident's condition or the medical symptoms being addressed by the use of grab bars. The assessment lacked documentation of education provided to the resident or his representative, and there was no review of the risks and benefits, including the risk of entrapment. The care plan for R194 indicated the need for assistance with bed mobility and transferring due to impaired functional mobility and a history of falls. However, the documentation did not include any evidence of education or informed consent regarding the use of grab bars. Interviews with staff revealed that while therapy and nursing staff were involved in the decision-making process, there was no formal documentation of the discussions or assessments conducted. The facility's policy required a physical device assessment with input from the interdisciplinary team, but this was not completed or documented. Observations and interviews with the resident and staff further highlighted the lack of communication and documentation. The resident did not recall receiving any education about the grab bars or being informed of the associated risks. Staff interviews indicated a lack of clarity and consistency in the process for assessing and installing bed mobility devices. The interim DON and regional nurse consultant acknowledged the expectations for assessment and monitoring but did not provide evidence of compliance with these procedures.
Inadequate PPE Usage During High-Contact Care
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) and appropriate personal protective equipment (PPE) were followed during high-contact care for two residents, R193 and R9, who required EBP for infection control. R193, with mild cognitive impairment and a bladder catheter, was observed without proper PPE usage by staff during care activities. LPN-A and NA-A did not wear gowns while assisting R193, despite signage indicating EBP requirements. LPN-A incorrectly believed that PPE was only necessary for catheter care and dressing changes, while NA-A confirmed not wearing PPE for boosting the resident in bed. R9, with significant cognitive impairment and multiple diagnoses, including chronic respiratory failure and pressure ulcers, also experienced inadequate PPE usage. An unidentified staff member and NA-E entered R9's room without donning gowns during high-contact care activities, such as repositioning and providing perineal care. NA-E acknowledged the requirement to wear a gown during such activities but failed to do so, resulting in direct contact between her clothing and R9's body and bedding. The facility's infection preventionist, IP-D, was responsible for training staff on EBP and ensuring compliance. Despite placing PPE carts and signage outside residents' rooms, IP-D was aware of frequent incidents of non-compliance with gown usage. The facility's policy on transmission-based precautions outlined specific high-contact activities requiring gown and glove use, which were not consistently followed by staff, leading to the deficiencies observed.
Failure to Document Advance Directives
Penalty
Summary
The facility failed to identify and document the preferences for health care directives for seven out of ten residents reviewed for advance directives. These residents included individuals with severe cognitive impairments and complex medical conditions such as multiple sclerosis, Alzheimer's disease, and cerebral infarction. Despite having care conferences and assessments, the facility did not ensure that advance directives or POLST forms were properly documented or signed by a provider. Interviews with social services staff revealed that they were responsible for reviewing residents' POLST and advance directives during care conferences. However, there was no evidence that the facility staff offered advance directive planning to the residents or their families. In one instance, a family member reported that attempts to discuss advance directives with the facility's admission staff were unsuccessful, and the resident was unable to communicate her wishes due to cognitive impairment. The Director of Nursing acknowledged that the facility relied on code status from hospital discharge papers and did not have a policy requiring advance directives or POLST forms. The facility lacked documentation of offering advance planning to residents, and there was no advance directive policy provided upon request. This deficiency highlights a significant gap in the facility's process for ensuring residents' rights to participate in their health care decisions.
Deficiency in BLS/CPR Certification Among Staff
Penalty
Summary
The facility failed to ensure that all licensed staff were properly trained and certified in Basic Life Support (BLS) and Cardiopulmonary Resuscitation (CPR), which is essential for providing emergency care to residents. Upon review, it was found that 18 out of 62 licensed staff members, including both Registered Nurses (RNs) and Licensed Practical Nurses (LPNs), did not have valid BLS/CPR certifications on file. Some staff members had expired certifications, and others had taken online courses without hands-on practice or in-person skill assessments. The facility's BLS/CPR book did not contain certificates for several staff members, and one LPN's certification was expired. Interviews with the staff development coordinator (SDC) and the director of nursing (DON) revealed that while BLS classes were offered twice a year, there was no system in place to ensure that staff maintained current certifications. The SDC admitted to reminding staff to submit their certificates but did not enforce any disciplinary actions for non-compliance. The DON and the administrator acknowledged the lack of a formal audit to verify staff certifications. Additionally, the facility did not provide a BLS/CPR policy when requested, indicating a lack of structured oversight in maintaining essential life-saving skills among staff.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor a resident's bathing preferences, leading to a deficiency in resident self-determination and choice. Resident R3, who was admitted with fractures and subsequent surgeries, preferred bed baths due to his medical condition. Despite this preference being documented in his care plan, the facility did not consistently provide bed baths or alternative bathing methods when R3 refused showers. Documentation showed that R3 only received one bed bath since admission, and there were multiple instances where bathing was not recorded or completed as per R3's preference. Observations and interviews revealed that R3 had not had his hair washed in ten weeks and was experiencing visible skin flakes and oily hair. R3 expressed his dissatisfaction with the lack of bed baths and stated that he had not been refusing them but rather requesting them without success. Staff interviews confirmed that R3 preferred bed baths and did not want to use the shower due to his surgical sites. However, there was a lack of consistent follow-up and documentation to ensure R3's preferences were honored. The facility's policies on bathing and resident dignity emphasized the importance of honoring resident preferences and providing at least one bath per week. However, the documentation and staff actions did not align with these policies. The Director of Nursing acknowledged the deficiency, noting that the expectation was for bed baths to be offered if a resident refused a shower, but this was not consistently documented or followed through in R3's case.
Failure to Revise Comprehensive Care Plan
Penalty
Summary
The facility failed to revise a comprehensive care plan for a resident (R3) who was admitted with multiple severe injuries, including fractures and dislocations in both lower extremities, and required specific medical interventions. Despite the resident's complex medical needs and a podiatry clinic note dated 4/1/24 that included critical instructions for wearing a cam boot and night splint, these instructions were not transcribed into the resident's electronic health record (EHR) or care plan. The care plan, initially developed on 3/7/24, did not reflect the updated medical orders, leading to a gap in the resident's care management. During an interview, the Director of Nursing (DON) acknowledged that the podiatry clinic note had not been transcribed into the resident's chart and confirmed that the care plan was not updated to include the new instructions. The facility's policy mandates that care plans be updated routinely to reflect the resident's current condition, but this was not adhered to in R3's case. The DON admitted that this oversight represented a breach in practice and protocol, potentially leading to harm due to the lack of adherence to the provider's instructions for the resident's care.
Failure to Ensure Adequate Supply and Administration of TPN
Penalty
Summary
The facility failed to ensure an adequate supply and administration of ordered medications for a resident diagnosed with multiple serious conditions, including colon cancer and gastro-esophageal reflux disease. The resident required total parenteral nutrition (TPN) and lipids, which were not administered as ordered on several occasions due to unavailability. Specifically, the medication administration record (MAR) indicated that TPN was not administered on the evening and night shifts of one day, and lipids were not administered on the day shift of the following day. Progress notes confirmed that the specialty pharmacy was unable to deliver the TPN on time, resulting in a missed dose. Interviews with the pharmacy technician and the director of nursing (DON) revealed that the facility typically received a seven-day supply of TPN per delivery, and the pharmacy technician would call weekly to check on the supply. However, a breakdown in communication and responsibility led to the TPN running out. The DON confirmed that nurses were responsible for tracking medication refills and ensuring an adequate supply, but in this instance, the TPN ran out, and the next delivery was delayed. Facility policy required reordering medications one week in advance and contacting the resident's family or physician if the medication did not arrive on time, but these steps were not effectively followed.
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Illustrative
What surveyors actually found near you
We read the 1,052 citations issued within 25 miles in the last 12 months — including the 33 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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hopkins
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sholom Home West | 0.9 mi | ★★★★★ | 7 | 0 |
| Hopkins Restorative Care Center | 1.3 mi | ★★★★★ | 23 | 0 |
| The Estates At St Louis Park Llc | 1.6 mi | ★★★★★ | 0 | 0 |
| The Villas At The Cedars | 2 mi | ★★★★★ | 15 | 1 |
| The Villas At St Louis Park | 2.7 mi | ★★★★★ | 18 | 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.