Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Cerenity Marian Of St Paul Llc during CMS and state inspections, most recent first.
A resident with moderately impaired cognition, cardiopulmonary disease, diabetes, and vision loss was found with a space heater operating in the room after stating the room felt too cool. The heater was set to 84 degrees, continued blowing warm air, and did not shut off when tipped over. Staff gave conflicting statements about whether space heaters were allowed, and the DON removed the heater after it was discovered.
Improper Maintenance of Supplemental Oxygen Equipment: A resident with chronic respiratory failure with hypoxia and dependence on supplemental O2 had a humidifying jar and tubing that were not properly dated and did not match the TAR. Staff confirmed the jar and tubing should be changed on a set schedule, and the DON stated nurses were responsible for maintaining the oxygen equipment.
Two residents in a facility received incorrect medications due to staff errors, resulting in one resident's hospitalization for hypotension and lethargy. The errors occurred when LPNs, unfamiliar with the unit, failed to verify resident identities, leading to significant medication errors. The facility's lack of adherence to medication administration protocols contributed to these incidents.
The facility failed to maintain proper dishwasher temperatures and food storage practices in three resident unit kitchenettes. Dishwashers did not consistently reach required sanitizing temperatures, and expired milk was found in the 3rd floor kitchenette. Additionally, clean dishes were stored under a dirty air grate on the 4th floor. Facility policies on dishwashing and food storage were not adequately followed, leading to potential risks for residents.
A resident suffered an ankle fracture due to unsafe transfer practices when staff failed to follow the care plan, which required the use of a standing lift. Multiple instances of improper transfer techniques were observed, including the absence of gait belts and lifting residents by the underarms. Staff interviews revealed a lack of awareness and understanding of care plans, contributing to preventable falls and injuries.
A resident, who was legally blind and not provided with hearing aids, fell during an incorrect transfer in the shower, resulting in a fracture. The incident was not reported immediately by the nursing assistant due to the RN being busy, leading to a delay in care for over 12 hours. The facility's policy required immediate reporting of such incidents, which was not followed.
The facility experienced staffing shortages, affecting the care and assistance provided to residents. Despite planning for 24 FTE nursing staff for a full census of 90 residents, the facility had an average census of 73 residents and struggled to maintain adequate staffing levels, often relying on agency staff. Daily Nursing Schedule forms indicated consistent shortages, particularly on the 4th floor, leading to delays in care and meal services. Specific instances included residents not receiving timely ADL assistance and missing meals, impacting their nutrition and hygiene. Staff members reported being rushed and unable to complete tasks effectively, highlighting systemic issues with staffing and workflow management.
The facility failed to ensure proper hand hygiene and PPE use for residents under contact and enhanced barrier precautions. Staff did not follow infection control policies, including wearing gloves and gowns, performing hand hygiene, and cleaning equipment between uses.
The facility failed to complete SAM assessments for three residents, leading to improper medication administration. One resident, despite being capable, was not allowed to self-administer medications, while another had multiple medications improperly stored in their room. A third resident was left with medication they did not want to take, contrary to facility policy.
A resident with broken eyeglasses did not receive a timely referral to an optometry service, despite the need being documented in his care plan and HealthDrive forms. The facility staff acknowledged the oversight, citing the eye doctor's maternity leave as a reason for the delay.
A resident with a pressure ulcer on the right heel did not receive the prescribed interventions, including CAM boot, Z-flex boots, and tubi grips. Observations and staff interviews confirmed that the resident's feet were often resting directly on the floor without the necessary protective equipment, contrary to the care plan and provider orders.
The facility failed to ensure food was served at warm, palatable temperatures for three residents. One resident reported that breakfast was often cold and delayed, another resident's family member noted that food was often cold or burned, and a third resident faced similar issues with food temperature. Observations revealed that food temperatures on the steam tables were below required levels, and staff acknowledged issues with maintaining proper food temperatures due to turnover and training inconsistencies.
The facility failed to label, date, and store food in a sanitary manner, leading to potential foodborne illness risks. Observations revealed improperly stored food in a resident's room and unlabeled meal trays. Staff interviews confirmed that food from outside sources should be labeled and stored in the kitchenette, as per facility policy.
The facility failed to provide timely ADL assistance for two residents, leading to missed meals and inadequate nutrition. One resident missed breakfast multiple times due to staff delays, while another was often still in bed during breakfast hours and only received toast when finally brought to the dining room. Staffing issues and poor time management were cited as contributing factors.
The facility failed to ensure a resident's individualized care plan was followed, resulting in the inconsistent use of a bed pan and urinal. The resident, who required assistance with toileting due to multiple medical conditions, did not have a urinal consistently placed at the bedside, and staff did not always offer the bed pan as required. This led to inadequate care for the resident's incontinence needs.
A facility failed to provide a therapeutic diet and ensure adequate hydration for a resident with multiple health conditions. The resident was often given non-compliant food items and did not always have water within reach. Staff were unaware of or did not follow the resident's dietary and hydration needs, and the facility's policies were not effectively implemented.
Space heater found operating in resident room
Penalty
Summary
The facility failed to ensure the environment was free of potential hazards for 1 resident, who was found with a space heater operating in the room. The resident’s quarterly MDS identified moderately impaired cognition, no behaviors, and independence with transfers and ambulation. Diagnoses included cardiopulmonary disease, diabetes, and eye conditions causing loss of vision. The resident’s mood state care plan identified sleep pattern disturbance related to insomnia and directed staff to evaluate the room for noise, darkness, temperature, and comfort. During observation, the resident stated the room was too cool and that nursing had provided a space heater. A [NAME] HFH610 space heater was observed on the laminate floor, set at 84 degrees, blowing warm air, and not shutting off when tipped over. The resident stated the heater was usually used only at night and was unsure how long it had been in the room. NA-A stated residents were not able to have space heaters in their rooms and was not aware of any in use, while RN-B stated it was okay to give a resident a space heater if they complained of being cold. The DON stated residents could not have space heaters in their rooms and removed the heater. The administrator stated the facility did not allow space heaters in resident rooms for safety reasons.
Improper Maintenance of Supplemental Oxygen Equipment
Penalty
Summary
The facility failed to ensure supplemental oxygen was properly maintained for a resident with chronic respiratory failure with hypoxia who was dependent on oxygen. The resident’s MDS indicated intact cognition and diagnoses of chronic respiratory failure with hypoxia and dependence on supplemental oxygen. Physician orders required continuous oxygen at 1 LPM via nasal cannula, weaning as able to keep oxygen saturation at or above 90%, and changing and dating the oxygen humidifying jar monthly. The care plan also directed staff to administer oxygen per order, check the humidifying jar daily, and change the humidifying jar and oxygen tubing weekly. During observations, the resident’s oxygen tank in the room had a humidifying jar with water that was dated 2/1/26, and the oxygen tubing had an illegible label that appeared to read either 2/8 or 3/8. The same condition was observed again the next day while the resident was on oxygen. RN-A confirmed the humidifying jar date and the illegible tubing label and stated the tubing should be changed weekly and the humidifying jar monthly. RN-B, RN-C, LPN-A, and the DON stated nurses were responsible for changing the oxygen tubing and humidifying jars, with standing orders for weekly tubing changes and monthly humidifying jar changes. LPN-A also confirmed the TAR showed the humidifying jar last changed on 3/1/26 and the tubing last changed on 3/12/26, which did not match the dates on the equipment. The facility policy on oxygen therapy did not address how often oxygen tubing or humidifying jars should be changed.
Medication Errors Lead to Hospitalization
Penalty
Summary
The facility failed to ensure medications were administered per physicians' orders, resulting in significant medication errors for two residents. One resident, with severe cognitive impairment and diagnoses of dementia, depression, and high blood pressure, received another resident's medications, including methadone and gabapentin, which were not prescribed to them. This error led to the resident experiencing hypotension, lethargy, and possible aspiration, necessitating emergent care and hospitalization. The error occurred when a licensed practical nurse (LPN) administered the wrong medications due to confusion between two residents with the same first name. The LPN, unfamiliar with the unit, failed to verify the correct resident before administering the medications. The resident's condition deteriorated, with blood pressure dropping significantly, prompting the administration of Narcan and transfer to a hospital for further monitoring. A second resident also received incorrect medications due to a similar error by another LPN, who was new to the facility. This resident, with severe cognitive impairment and multiple diagnoses, was given medications intended for a neighboring resident. Although the medications were not deemed dangerous, the resident was sent to the emergency department for cardiac monitoring due to concerns about potential interactions. The facility's failure to adhere to the seven rights of medication administration and proper resident identification procedures contributed to these errors.
Dishwasher Temperature and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain proper dishwasher temperatures in three kitchenettes located on resident units, which compromised the sanitation of resident dishes. Observations revealed that the dishwashers on the 4th floor did not reach the required wash temperature of 155 degrees Fahrenheit, with logs showing consistent failures over multiple days. Additionally, the 3rd floor dishwasher also failed to meet the necessary rinse temperature of 180 degrees Fahrenheit on several occasions. Interviews with culinary aides and the culinary director confirmed that the dishwashers were intended to use high temperatures for sanitization, but the temperature logs did not consistently reflect compliance with these standards. Further deficiencies were noted in the handling and storage of food items. On the 3rd floor, expired milk was found in the refrigerator, and some milk containers lacked best by dates. The culinary aide acknowledged the oversight and removed the expired items. The culinary director was unaware of the missing dates on milk cartons and expected a process to ensure dates were known. Additionally, on the 4th floor, clean dishes were stored under a dirty air grate, which posed a risk of contamination from dust and debris. Maintenance staff were uncertain about the cleaning responsibilities for the vents. The facility's policies on dishwashing and food storage were not adequately followed. The dishwashing procedures required adherence to manufacturer instructions, including a final sanitizing rinse of 180 degrees Fahrenheit, which was not consistently achieved. The food storage policy did not provide clear guidance on reviewing best by dates for perishable items. The administrator expected compliance with these guidelines to ensure resident safety and cleanliness, but the deficiencies indicated lapses in monitoring and adherence to established protocols.
Unsafe Transfer Practices Lead to Resident Injury
Penalty
Summary
The facility failed to provide safe transfers according to the care plan for four residents who required staff assistance, resulting in an immediate jeopardy situation for one resident who suffered an ankle fracture during a transfer. The incident occurred when a nursing assistant did not follow the care plan, which specified the use of a standing lift for transfers. Instead, the resident was pivot transferred by one staff member, leading to a fall and subsequent injury. The resident's care plan had identified her as at risk for falls due to a history of falls, weakness, and other medical conditions, and required the use of a mechanical standing lift for transfers. The report details multiple instances where staff did not adhere to care plans, resulting in unsafe transfer practices. For example, one resident was transferred without the use of a gait belt, and another was lifted by the underarms instead of using the proper technique. These actions were contrary to the facility's policies and the residents' care plans, which required the use of gait belts and mechanical lifts to ensure safe transfers. Interviews with staff revealed a lack of awareness and understanding of the care plans and proper transfer techniques, contributing to the unsafe practices observed. The facility's failure to follow care plans and ensure safe transfer practices led to preventable falls and injuries. Staff interviews indicated a lack of communication and reporting of incidents, as well as inadequate training on the use of assistive devices and proper transfer techniques. The report highlights the need for staff to be aware of and adhere to care plans to prevent harm to residents, as well as the importance of timely reporting and assessment of falls to ensure appropriate care and treatment.
Failure to Report Fall Incident and Delay in Care
Penalty
Summary
The facility failed to report an incident involving a fall immediately to the supervisor, as required by the facility's abuse policy, for a resident who suffered a fracture during an unsafe transfer. The resident, who was legally blind and not provided with hearing aids prior to the transfer, reported being transferred incorrectly in the shower, causing her to fall and sustain a fracture. The incident led to a delay in care and treatment for over 12 hours. The resident's quarterly Minimum Data Set (MDS) identified her as cognitively intact with moderate difficulty in hearing and highly impaired vision. The resident required substantial assistance with footwear and was not assessed for tub/shower transfer. On the evening of the incident, a nursing assistant transferred the resident using a standing pivot instead of the prescribed standing mechanical lift, resulting in the resident being assisted to the floor. The nursing assistant did not report the fall or the resident's new onset of pain to the registered nurse or oncoming staff, leading to a lack of immediate medical assessment. Interviews with staff revealed that the nursing assistant did not report the incident due to the registered nurse being busy and having a bad attitude. Other nursing assistants involved in assisting the resident off the floor also failed to notify a nurse of the incident. The registered nurse on duty was unaware of the fall and reported the resident as fine during the shift change. The facility's policy required staff to report incidents immediately to their supervisor, but this protocol was not followed, resulting in a delay in addressing the resident's injury.
Staffing Shortages Impact Resident Care and Assistance
Penalty
Summary
The facility failed to provide sufficient staffing to ensure residents received the necessary care and assistance, potentially affecting all 82 residents. The facility's 2023 Annual Facility Assessment indicated a capacity for 90 residents but had an average census of 73 residents, with services including ADL support, medication administration, and fall prevention. Despite planning for 24 FTE nursing staff at full census, the facility struggled with staffing shortages, relying on agency staff as needed. Daily Nursing Schedule forms revealed consistent shortages, particularly on the 4th floor, leading to challenges in providing timely care and meals to residents. Observations and interviews highlighted specific instances where residents did not receive adequate care due to staffing issues. For example, residents R9 and R38 did not receive timely ADL assistance and missed meals, impacting their nutrition and hygiene. Staff members expressed concerns about being short-staffed, leading to rushed care and difficulties in completing tasks effectively. The facility's policies emphasized the importance of sufficient staffing levels to meet residents' needs, but the reality reflected ongoing challenges in maintaining adequate staffing levels to provide quality care. The deficiency was further underscored by the experiences of residents like R1, who required substantial assistance with eating and toileting hygiene. Despite care plans and physician orders specifying dietary needs, observations revealed instances where R1 did not receive timely meals or assistance with feeding. Staff members acknowledged gaps in providing necessary care, indicating systemic issues with staffing and workflow management that impacted residents' well-being and quality of care.
Failure to Ensure Proper Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to ensure proper hand hygiene and the use of personal protective equipment (PPE) for residents under contact precautions and enhanced barrier precautions. Specifically, a nursing assistant entered a resident's room without wearing gloves or a gown, handled the resident's meal tray, and moved the bedside table without following the required precautions. The resident was on contact precautions due to suspected Norovirus, and the staff member's actions were contrary to the facility's infection control policies. Interviews with staff confirmed that PPE should have been worn, and hand hygiene should have been performed when entering and exiting the room. Another incident involved a resident who required peri care and was transferred using a mechanical lift. The certified nursing assistant did not remove soiled gloves or perform hand hygiene after providing peri care and immediately handled the resident's oxygen nasal cannula. Additionally, the mechanical lift was not cleaned after use, which is against the facility's protocol. Interviews with staff confirmed that mechanical lifts should be cleaned between residents to prevent cross-contamination. A third incident involved a resident on enhanced barrier precautions due to infections with ESBL and MRSA. During morning care, a nursing assistant used the same gloves and washcloth to clean different areas of the resident's body, including an open wound. The same gloves were also used to apply ointment to the wound. Furthermore, staff were observed not wearing gowns or gloves while providing care to the resident, despite the requirement for enhanced barrier precautions. Interviews with staff revealed confusion about when gowns should be worn, indicating a lack of adherence to the facility's infection control policies.
Failure to Complete SAM Assessments and Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure a self-administration of medication assessment (SAM) was completed for three residents (R70, R11, R52) to allow them to safely administer their own medications. For R70, despite having intact cognition and a physician's order to self-administer medications, the SAM assessment was not completed. R70 expressed frustration about not being allowed to self-administer medications, stating it was demoralizing to have staff stand over him. Interviews with staff confirmed that R70 was capable of making his own decisions and should have had a SAM assessment completed, but it was not done due to a misunderstanding of the assessment process and criteria. For R11, who was cognitively impaired and on hospice care, the SAM assessment indicated that R11 did not want to self-administer medications, and no further action was taken. However, during an observation, multiple medications, including expired and unlabeled ones, were found in R11's room. This included a bottle of nystatin powder that belonged to another resident. The DON clarified that all medications should be kept in medication and treatment carts and not in residents' rooms, indicating a lapse in following the facility's medication storage policy. R52, also cognitively impaired and on hospice care, had a SAM assessment indicating no desire to self-administer medications. However, during an observation, a medication cup with two white pills was left in front of R52, who stated she did not want to take the medication and had spit it out. The TMA confirmed that R52 often refused care and medications. The DON stated that staff were expected to observe residents taking their medications unless a SAM assessment indicated they could do so independently, which was not adhered to in this case.
Failure to Provide Timely Optometry Referral
Penalty
Summary
The facility failed to provide a timely referral to an outside optometry service for a resident whose glasses were broken. The resident, who had intact cognition and required glasses for reading, reported that the temple part of his eyeglasses had been broken for about a year, making it difficult for him to use his computer and read puzzles. Despite the resident's need for new glasses and a follow-up appointment, the facility did not arrange for an optometry visit, and there were no documented refusals of eye exams in the resident's progress notes after a certain date. The resident's care plan indicated that he required reading materials and puzzles and had a history of vitreous detachment, which could affect vision. The facility used a service called HealthDrive to provide optometry services, and the resident had consented to be seen for eye care. However, the last documented optometry visit was several months prior, and the resident's glasses were not repaired or replaced despite the need being noted in his care plan and HealthDrive forms. Interviews with facility staff revealed that the Health Information Manager (HIM) was responsible for managing HealthDrive visits, but there was a lack of follow-up on the resident's need for new glasses. The Director of Nursing (DON) and other staff members acknowledged that the resident should have had an eye appointment if a follow-up was ordered. The DON later stated that the resident was not seen by optometry because the eye doctor was on maternity leave, and there was no policy provided to address the issue.
Failure to Implement Pressure Ulcer Interventions
Penalty
Summary
The facility failed to ensure proper interventions were in place for a resident with a pressure ulcer on the right heel. The resident, who had moderate cognitive impairment and lymphedema, was observed multiple times without the prescribed CAM boot, Z-flex boots, or tubi grips. Despite orders for these interventions to be used consistently to offload pressure and protect the heel, the resident was seen with feet resting directly on the floor and without the necessary protective equipment. Interviews with staff confirmed that the resident did not have the required boots on while in bed or during transfers, and the tubi grips were not applied as ordered. The resident's care plan and provider orders clearly indicated the need for specific interventions to prevent further skin breakdown and promote healing. However, observations and staff interviews revealed that these interventions were not consistently implemented. The resident reported that staff were not applying the boots as required, and multiple staff members, including registered nurses and nursing assistants, acknowledged the failure to follow the prescribed care plan. The facility's policy on the prevention and treatment of skin breakdown was not adhered to, resulting in inadequate care for the resident's pressure ulcer.
Failure to Serve Food at Proper Temperatures
Penalty
Summary
The facility failed to ensure food was served at warm, palatable temperatures for three residents. Resident 9 (R9) reported that carrots were not cooked properly and were difficult to chew. R9's care plan indicated a preference for hot meals and ice in cold drinks, but during an interview, R9 stated that he had to wait until lunch to eat because breakfast was not served on time, and when it was served, it was often cold. R9 also mentioned that this had happened three or four times, and he preferred to be up around 9:00 a.m. but was not assisted out of bed until 10:30 a.m. on the day of the observation. The dietary aide (DA) confirmed that the steam table temperatures were below the required levels, and the culinary director (CD) acknowledged that there were issues with maintaining proper food temperatures due to staff turnover and training inconsistencies. R9 did not receive breakfast on the day of the observation because the staff was running behind, and he was not offered his preferred oatmeal and scrambled eggs. Resident 64 (R64) also experienced issues with food quality. R64's family member reported that the food was often cold, not cooked enough, or sometimes burned. R64's care plan indicated that the resident was on hospice and had difficulties feeding himself due to Parkinson's disease. The family member's concerns about the food quality were consistent with the observations made during the survey. The dietary aide's temperature checks on the steam tables revealed that the food temperatures were significantly below the required levels, with poached eggs and Canadian bacon at 110 degrees Fahrenheit, scrambled eggs at 130 degrees, and oatmeal at 125 degrees. The CD confirmed that the holding temperature for foods on the steam table should be at 145 degrees and acknowledged that the temperatures obtained by the DA were low. Resident 50 (R50) also faced issues with food temperature. R50's care sheet indicated a preference to get out of bed by 8:00 a.m., but during the observation, it was noted that breakfast service started at 7:30 a.m. and went until 9:00 a.m. The DA verified that there were still residents who had not eaten, including R50. The CD stated that the temperatures in the kitchen were checked before food was brought up to the floors, but due to staff turnover and training inconsistencies, temperatures were not consistently completed. The facility's policy on maintaining proper food temperatures indicated that hot food should be maintained at 135 degrees Fahrenheit or higher during tray assembly, but the observations and interviews revealed that this standard was not met, leading to the deficiency in food service quality for the residents involved.
Failure to Label and Store Food Properly
Penalty
Summary
The facility failed to label, date, and store food in a sanitary manner, which could potentially lead to foodborne illnesses. During observations, a small glass containing orange liquid was found on a resident's bedside table, and an open jar of salsa was observed on the windowsill. The resident confirmed that the orange liquid was from breakfast and had been consumed later in the day. The jar of salsa remained on the windowsill for several days. Additionally, two meal trays were found on the counter outside the kitchenette without proper labeling, making it impossible to determine how long they had been sitting out. Interviews with staff, including the culinary director, CNAs, and the unit manager, revealed that food brought into the facility from outside sources should be labeled with the resident's name, date, and time, and stored in the kitchenette. The facility's policy also indicated that perishable items should be stored in the kitchenette fridge and labeled accordingly. The administrator confirmed that food brought into the facility must be labeled and stored properly to prevent foodborne illnesses. The facility's failure to adhere to these protocols was evident in the observations and staff interviews.
Failure to Provide Timely ADL Assistance
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADL) for two residents, R9 and R38, who required staff assistance to attend meals. R9, who had intact cognition and required substantial assistance with mobility and transfers, missed breakfast on multiple occasions because staff did not get him out of bed in time. Despite R9's preference to be up by 9:00 a.m., staff were often behind schedule, leading to R9 missing breakfast and having to wait until lunch to eat. On one occasion, R9 was offered toast instead of his preferred oatmeal and scrambled eggs, which he declined because he did not eat bread. R9 expressed frustration about missing breakfast and having to eat cold food when served late. R38, who had moderate cognitive impairment and required extensive assistance with transfers and toileting, also missed breakfast due to staff delays. Despite a care plan intervention to bring R38 to the dining room at least 30 minutes before meals, R38 was often still in bed during breakfast hours. On one occasion, R38 was brought to the dining room late and was only offered toast, which he ate because he was hungry. Staff interviews revealed that the facility was short-staffed, and the aides were struggling to get residents up in a timely manner, especially those requiring mechanical lifts. The facility's policy on ADLs emphasized the importance of providing residents with the necessary care to maintain good nutrition, grooming, personal hygiene, and mobility. However, due to staffing issues and poor time management, residents like R9 and R38 were not receiving timely assistance, leading to missed meals and inadequate nutrition. The director of nursing acknowledged the staffing challenges and the need for better time management to ensure residents received their meals on time.
Failure to Provide Appropriate Incontinence Care
Penalty
Summary
The facility failed to ensure the use of a bed pan and urinal were offered and in place for a resident (R38) in accordance with the individualized care plan. R38, who had mild cognitive impairment, hemiplegia, hemiparesis, and other medical conditions, required assistance with toileting and was frequently incontinent of bladder and bowel. The care plan indicated that R38 should have a urinal within reach at the bedside and be offered a bed pan if preferred. However, observations and interviews revealed that the urinal was not consistently placed at the bedside, and staff did not always offer the bed pan to R38 as required by the care plan. Additionally, the care sheet lacked information about having a urinal at the bedside, leading to inconsistencies in care provided by the staff. During multiple observations, it was noted that the urinal was often found in the bathroom rather than at the bedside, and staff did not offer the bed pan to R38. Interviews with nursing assistants and the licensed practical nurse confirmed that they were not fully aware of the care plan requirements, and the care sheet did not specify the need for the urinal to be at the bedside. The director of nursing also acknowledged that the urinal should have been at the bedside. This failure to adhere to the care plan resulted in inadequate care for R38, as the resident was not provided with the necessary tools to manage incontinence effectively.
Failure to Provide Therapeutic Diet and Adequate Hydration
Penalty
Summary
The facility failed to provide a therapeutic diet as prescribed and ensure adequate hydration for a resident with multiple health conditions, including hemiplegia, dementia, and dysphagia. The resident's care plan indicated the need for a heart-healthy diet and specific hydration protocols, but these were not consistently followed. Observations and interviews revealed that the resident was often given food items not compliant with the prescribed diet, such as bacon and salami sandwiches, and was not always provided with water within reach, leading to concerns about dehydration. The resident's meal tickets did not always match the prescribed diet, and staff were observed offering non-compliant food items. For instance, the resident was given bacon and a Danish cherry strudel for breakfast, despite being on a low-sodium, low-fat diet. Additionally, the resident's water pitcher was frequently placed out of reach, and staff did not consistently offer fluids as required by the care plan. Interviews with staff indicated a lack of awareness and adherence to the resident's dietary and hydration needs, with some staff members unaware of the specific requirements or failing to follow them. The facility's policies on diet orders and resident noncompliance with provider-ordered diets were not effectively implemented. The registered dietitian confirmed that the resident's menu should have been adjusted to meet the heart-healthy diet requirements, and deviations from the diet should have been documented. However, there was no documentation of the resident's noncompliance or any attempts to offer acceptable food substitutes. The director of nursing acknowledged the failure to ensure the water pitcher was within reach and the need to update the care plan to reflect the resident's hydration needs.
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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) |
|---|---|---|---|---|
| Cerenity Care Center On Humboldt | 1.8 mi | ★★★★★ | 12 | 0 |
| Capitol View Transitional Care Center | 2 mi | ★★★★★ | 1 | 0 |
| Ebenezer Integrated Care & Rehab | 2.2 mi | ★★★★★ | 6 | 0 |
| Little Sisters Of The Poor | 2.4 mi | ★★★★★ | 5 | 0 |
| The Villas At St Paul | 2.7 mi | ★★★★★ | 3 | 0 |
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