Above average — CMS composite of the measures below.
The next survey window likely opens around October 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 Capitol View Transitional Care Center during CMS and state inspections, most recent first.
A resident with multiple diagnoses had a skin tear on the right forearm covered by an undated mepelix dressing, but the wound was not fully assessed, documented, or tracked in the EMR. Skin assessments lacked the wound location and any treatment details, provider and nursing orders did not include wound care orders, and the care plan did not identify the skin tear or skin injury risk. Staff later stated the dressing had not been checked under, no LDA had been created, and no progress note showed when the dressing was placed or changed.
A resident with cognitive impairment and recent GI surgery reported to a nursing assistant that an RN had put hands on her neck and pushed her back into bed, causing fear but no physical harm. The nursing assistant did not immediately escalate the allegation, and the RN, after learning of the report, did not notify the administrator or DON as required. The incident was only reported to the DON days later by a social worker, delaying the required notification to the State Agency.
A resident was observed with medications at the bedside without a completed self-administration assessment. Despite having intact cognition and a temporary care plan indicating the ability to self-administer inhalers, the physician's orders lacked confirmation. The RN and DON were unable to find documentation in the medical record, highlighting a failure to follow the facility's policy requiring a comprehensive assessment for self-administration.
The facility failed to properly label and track expiration dates for insulin medications for two residents with type two diabetes. A nurse administered insulin from an unlabeled vial and assumed an incorrect expiration period, while another nurse did not document the expiration date on an opened vial. The facility's policy required proper labeling and dating, but it was not consistently followed.
Failure to Monitor and Document a Skin Tear
Penalty
Summary
The facility failed to ensure continued monitoring and treatment of a skin tear for one resident who was recently admitted with diagnoses including pathological compression fractures of the cervical spine and squamous cell cancer involving the bone. The resident’s wound care alert noted a skin tear on the right forearm covered with a mepelix foam dressing, but the document did not include an assessment or description of the injury. Daily skin assessments documented that the resident had a skin tear, but they did not identify the location or indicate whether any further monitoring or treatment was provided. Provider and nursing orders did not include treatment orders for the skin tear, and the temporary care plan did not identify the resident as having a current skin tear or being at risk for skin injury. During observation, the resident had an undated mepelix dressing on the right forearm and was unsure what was underneath it or when it had been placed. Nursing staff stated the resident had bruises and bumps frequently. An RN initially believed the skin tear had occurred before admission and stated no care had been provided or the dressing checked under the mepelix; later, after removing the dressing, the RN stated it appeared to be a skin tear that was almost completely healed and believed it had been placed by the facility. The DON stated that skin alterations were expected to be documented on the body audit and that nurses should peel back a mepelix to determine the condition of the skin injury, but the resident’s body audit did not show the forearm skin alteration, no LDA had been created, and no progress note could be found showing when the dressing was placed or changed.
Failure to Immediately Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident with moderately impaired cognition and a recent gastrointestinal surgery was reported to the State Agency immediately, as required. On the evening of the incident, the resident reported to a nursing assistant that a registered nurse had put hands on her neck and pushed her back into bed, causing the resident to feel shocked and afraid, though not physically harmed. The nursing assistant told the resident he would report the incident to someone higher, but the registered nurse, after being informed of the allegation, returned to the resident's room to discuss the situation instead of reporting it to the administrator or DON. The delay in reporting was confirmed when the DON stated that the allegation was only brought to her attention several days later by a social worker, at which point an investigation was initiated. The facility's policy required immediate reporting of any abuse allegations to the administrator, but this protocol was not followed. No formal re-education was provided to staff regarding the importance of immediate reporting, and the registered nurse continued to work with the resident after the incident.
Failure to Complete Self-Administration Assessment for Resident
Penalty
Summary
The facility failed to ensure a self-administration of medications (SAM) assessment was completed for a resident, identified as R171, who was observed with medications at the bedside. R171 was admitted to the facility with several fractures and osteoporosis, and had intact cognition according to the temporary care plan. The resident's temporary care plan indicated that they could self-administer inhalers at the bedside. However, the physician's orders did not include information allowing R171 to self-administer inhalers. An admission progress note indicated that R171 had limited use of their arms, which could impact their ability to self-administer medications. During an observation, a registered nurse (RN) found inhalers at R171's bedside and was unsure if the resident was permitted to self-administer them, as there was no documentation in the medical record confirming this. The director of nursing (DON) stated that an assessment should be completed and documented in the electronic medical record if a resident can self-administer medications. However, upon review, the DON did not find any documentation indicating that R171 had been assessed for self-administration. The facility's policy requires a comprehensive assessment of a resident's ability to self-administer medications, which was not completed in this case.
Medication Labeling and Expiration Tracking Deficiency
Penalty
Summary
The facility failed to ensure proper labeling and expiration tracking of medications, specifically insulin, for two residents. For one resident with type two diabetes, a registered nurse administered insulin from a vial that was not labeled with the resident's information and did not have a documented expiration date. The nurse assumed the insulin expired after one month and labeled it accordingly, despite the correct expiration period being 28 days. The pharmacist consultant confirmed that insulin stored in drawers with multiple residents should have identifiable information. For another resident, also with type two diabetes, a licensed practical nurse explained the process of dispensing medications but failed to document the expiration date on an opened insulin vial. The nurse initially believed the expiration period was 30 days but later clarified it was 28 days. The director of nursing stated that their policy required insulins to be labeled with the patient's name, date of birth, physician, and medical record number, and to be dated when opened. However, the facility's policy was not consistently followed, leading to the deficiencies observed.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Saint Paul
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ebenezer Integrated Care & Rehab | 0.5 mi | ★★★★★ | 6 | 0 |
| The Villas At St Paul | 0.7 mi | ★★★★★ | 3 | 0 |
| Little Sisters Of The Poor | 1.1 mi | ★★★★★ | 5 | 0 |
| The Emeralds At St Paul Llc | 1.2 mi | ★★★★★ | 0 | 0 |
| Cerenity Care Center On Humboldt | 1.8 mi | ★★★★★ | 12 | 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.