Above average — CMS composite of the measures below.
The next survey window likely opens around March 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 Ebenezer Integrated Care & Rehab during CMS and state inspections, most recent first.
A resident with diabetes mellitus type 2 and daily insulin orders had BG monitoring ordered before meals and at bedtime, with sliding-scale insulin to be given with meals. During morning med pass, an LPN gave oral meds, then checked the resident’s BG after he had already started eating breakfast and administered insulin based on that result. The resident and multiple nurses, including the DON, stated BG should be checked before meals to obtain an accurate fasting BG, and facility policy required BG monitoring per provider order.
Failure to Implement Active Fall-Prevention Interventions: A resident with severe cognitive impairment, vascular dementia, poor balance, and a high fall-risk score had repeated falls from his wheelchair and one fall from bed. The care plan included keeping wheelchair footrests upright when not propelling because he had previously tripped over them, but survey observation found his feet on the footrests while they remained down, with staff nearby yet not correcting the intervention as written. Staff interviews confirmed the intervention was still active and should have been followed for safety.
Failure to Arrange Routine Dental Services: A resident who was cognitively intact and dependent on staff for oral hygiene did not receive assistance in obtaining routine dental care. The resident had hemiplegia/hemiparesis and a care plan for substantial to dependent help with oral care, yet the record showed no dental appt or documented offer of referral, and the resident stated he had not seen a dentist since admission. Staff and the DON acknowledged that residents without a recent dental visit should be offered and arranged routine dental services per facility policy.
A resident with hemiplegia and multiple chronic conditions was injured after staff failed to follow the prescribed transfer protocol, which required assist of one with a gait belt, walker, and wheelchair positioned behind. During a toileting transfer, a new nursing assistant was unable to fit the wheelchair in the bathroom and attempted to move both the walker and wheelchair while supporting the resident, resulting in a fall and a fractured shoulder. Documentation and interviews confirmed the care plan was not followed, leading to actual harm.
Staff did not consistently follow Enhanced Barrier Precautions or perform proper hand hygiene during high-contact care activities for residents with wounds or other infection risks. Observations showed that staff failed to wear required gowns and gloves, did not always change gloves or sanitize hands between tasks, and handled soiled linens and resident equipment without appropriate PPE, despite facility policies and care plans indicating these measures were necessary.
A resident with a known severe allergy to ginger was served a meal containing the allergen, leading to an anaphylactic reaction. The facility failed to administer epinephrine due to insurance issues and lack of availability in the emergency kit. The resident's allergy was not accurately reflected in the nutrition program, and the meal tray ticket did not list the allergy, resulting in the resident consuming the allergen. Staff interviews revealed communication and procedural failures in managing the resident's dietary needs and emergency preparedness.
The facility failed to ensure that residents were offered and provided updated pneumococcal and influenza vaccinations according to CDC guidelines. Four residents with conditions increasing their risk for pneumococcal diseases lacked documentation of shared decision-making discussions, declinations, or risk-benefit discussions for additional vaccinations. The infection preventionist and DON confirmed the lack of documentation, despite facility policies requiring such records.
A resident with dementia was left exposed and undignified during personal care by two nursing assistants, despite her protests. The staff failed to cover her adequately, leaving her exposed when a registered nurse entered the room. Interviews with staff revealed an expectation to maintain dignity, but the involved staff admitted to not considering it during the care process.
A resident with a history of stroke, aphasia, dementia, and hemiplegia was found with Tums at his bedside without a self-administration assessment or provider order. Nursing staff confirmed the oversight and acknowledged the need for an assessment and order per facility policy, which was not completed, posing potential risks of medication interactions.
A facility failed to notify a physician of a resident's significant weight gain despite orders to do so, and also failed to follow prescribed wound care orders for another resident. The resident with CHF experienced substantial weight gain, but the physician was not informed as required. Additionally, a nurse applied incorrect wound treatment to a resident with MASD, using Medihoney instead of the prescribed Mepilex dressing. These actions were contrary to the facility's policies and care plans.
A resident with cognitive impairment, dementia, stroke, and dysphasia did not receive the necessary adaptive equipment, a nosey cup, during meals. Despite the care plan and meal tickets indicating the need for a nosey cup, observations showed the resident's meal trays lacked this equipment. Staff interviews confirmed the expectation for dietary staff to provide and nursing staff to use the adaptive equipment, but there was a failure in communication and execution.
The facility failed to ensure proper hand hygiene and infection control during care for two residents with cognitive impairments. Nursing assistants did not change gloves or perform hand hygiene after handling soiled items, and inappropriate cleaning methods were used. Interviews confirmed that expected procedures were not followed, and the facility's policies were inadequate.
A resident with known food allergies experienced an anaphylactic reaction after consuming a meal containing ginger, despite being assured by staff that it was not present. The resident's epinephrine was unavailable due to insurance issues, leading to hospitalization. The facility failed to report the incident to the State Agency in a timely manner, as required by policy.
A resident with a known ginger allergy experienced an anaphylactic reaction after consuming a meal containing ginger. The facility failed to have epinephrine available due to insurance issues, and the resident was sent to the hospital. The incident was not investigated or reported to the State Agency in a timely manner, contrary to facility policy.
A resident with dementia and moderate cognitive impairment, who was at risk for falls, slid out of her wheelchair during transportation to an appointment. The facility failed to conduct a post-fall assessment and update interventions to prevent future falls. Staff interviews revealed the resident frequently attempted to slide out of her wheelchair, and a reclining wheelchair was suggested for safer transportation. The director of nursing was not informed of the resident's risk, indicating a communication breakdown.
A resident with impaired cognition and a history of wandering was taken out of the facility by a family member, despite instructions in the EHR to prevent such outings. The resident fainted at a train station and was hospitalized. Staff miscommunication and lack of awareness of the resident's restrictions contributed to the incident.
Two residents in an LTC facility experienced significant medication errors due to transcription issues. One resident did not receive vortioxetine for over a month due to a missed transcription in the EHR. Another resident's Abilify was discontinued prematurely, leading to a resurgence of hallucinations. The facility's transcription process failed to ensure orders were double-checked and properly entered into the system.
A nursing assistant failed to remove gloves and wash hands after changing a resident's brief, performing multiple tasks without proper infection control. Interviews confirmed the lapse, and the facility's policy lacked specific guidelines.
A facility failed to ensure a pressure relief air mattress was properly assessed for safe size in relation to the bed frame and grab bars for a resident, leading to significant gaps and potential entrapment risks. Despite the resident's need for assistance and the use of grab bars, the mattress moved freely, creating unsafe conditions that were not appropriately addressed by staff or the vendor.
A facility failed to coordinate hospice services for a resident with severe cognitive impairment and schizoaffective disorder. The resident's medical record lacked essential hospice documentation, and there were ongoing coordination issues with the hospice agency, including incomplete forms and incorrect contact information. The hospice director acknowledged these deficiencies, and the facility's hospice contract and policy requirements were not met.
BG Checked After Breakfast Before Sliding-Scale Insulin
Penalty
Summary
The facility failed to ensure fasting blood glucose (BG) testing was performed before a meal for a resident with diabetes mellitus type 2 who required insulin based on a sliding scale. The resident’s quarterly MDS indicated he was cognitively intact, dependent on staff for most ADLs, received insulin daily during the lookback period, and had a diagnosis of diabetes mellitus. His care plan directed staff to monitor blood sugars per provider order and as needed, and provider orders required BG monitoring four times daily before meals and at bedtime, with insulin aspart to be given with meals according to the BG result. During observation, the resident was sitting up in bed with a breakfast tray in front of him and had already eaten most of his breakfast and some of his beverages when the LPN entered to give morning medications. The LPN gave oral medications, then checked the resident’s BG after he had already started eating, obtaining a result of 175 and administering 1 unit of insulin based on the sliding scale. The resident stated BG should be checked before meals because the insulin amount was based on the BG result. The LPN, RN-C, RN-A, and the DON each stated BG should be checked before breakfast or before meals to obtain an accurate fasting BG, and that a BG taken during or after eating could result in an incorrect insulin dose. Facility policy instructed staff to monitor BG levels per provider order.
Failure to Implement Active Fall-Prevention Interventions
Penalty
Summary
The facility failed to ensure active fall-prevention interventions were implemented for a resident with severe cognitive impairment, vascular dementia, poor balance, shuffling gait, incontinence, and a high fall-risk score. The resident used a walker and wheelchair and required substantial to maximal assistance for transfers, ambulation, toileting, lower body dressing, and bed mobility. His annual CAA and fall risk assessment identified him as high risk for falls, with contributing factors including poor judgment, poor safety awareness, deconditioning, and a history of falls. The resident had repeated falls from his wheelchair and one fall from bed. On multiple occasions, he was found on the floor after attempting to stand or transfer without assistance, including an unwitnessed fall with a left upper eyelid laceration and another witnessed fall when his wheelchair tipped as he stood in the dining room. The fall investigations repeatedly identified misjudgment of ability, cognitive impairment, weakness, poor balance, and, in one instance, wheelchair footrests being in the down position as contributing factors. The care plan included an intervention to keep the wheelchair footrests in the upright position when not propelling because he had previously tripped over them. During survey observation, the resident was seen seated in his wheelchair with his feet on the footrests while the footrests were not in the upright position, which conflicted with the care plan. Staff were nearby but did not correct the footrest position for an extended period, and the resident remained in the commons area with intermittent staff presence rather than direct supervision. Staff interviews confirmed that the footrest intervention was still active and should have been followed as written, and the DON stated staff should review and implement fall interventions from the care plan or Kardex for safety.
Failure to Arrange Routine Dental Services
Penalty
Summary
The facility failed to assist in obtaining routine dental services for 1 resident reviewed for dental services. The resident’s quarterly MDS indicated the resident was cognitively intact, dependent on staff for oral hygiene, and did not exhibit rejection of care behavior. The resident’s diagnoses included hemiplegia and hemiparesis, and the care plan identified a self-care performance deficit requiring substantial to dependent assistance with personal hygiene and oral care. An oral/dental assessment noted no oral concerns, but the resident was considering partials for edentulous upper and lower premolars. The resident’s medical record lacked evidence of a dental appointment or any reference to an offer for dental referral, and the resident stated he had not seen a dentist in at least a year and a half and had not been offered dental services since admission. Staff interviews indicated that if a resident had not seen a dentist in over two years and had not declined an appointment, a referral should be made, and the facility was responsible for scheduling and coordinating dental consultations. The HUC confirmed the resident did not have a dental appointment scheduled and had not seen a dentist since admission, and the DON stated dental referral should be recommended and arranged per resident preference. The facility policy required staff to refer the resident for an initial dental examination within 90 days of admission unless a dental exam had occurred within six months before admission, and to offer an annual dental exam within one year of the previous exam.
Failure to Follow Care Plan for Safe Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to follow the care plan interventions required for safe transfers of a resident with significant physical impairments. The resident had a history of hemiplegia and hemiparesis following a cerebrovascular event, as well as other chronic conditions including heart failure, COPD, diabetes, and atrial fibrillation. The care plan specified that the resident required assistance of one staff member with a gait belt and two-wheeled walker, with a wheelchair to follow during transfers, and contact guard assist. Despite these directives, the resident was ambulated without the required contact guard assist and without the wheelchair positioned behind her. During a toileting transfer, a new nursing assistant, on her first solo day, was unable to fit the wheelchair into the bathroom with the walker. The assistant attempted to manage the transfer by holding the gait belt while moving the walker and then the wheelchair, resulting in the resident needing to take several unsupported steps. The resident became unsteady and fell, sustaining a comminuted fracture of the proximal humerus. Documentation and interviews confirmed that the care plan was not followed during this transfer, and the wheelchair was not positioned as required. The incident was reported by the nursing assistant, and subsequent documentation indicated that the resident's care plan had not been adhered to at the time of the fall. The facility's policies required staff to follow the care plan or Kardex for transfers, and the failure to do so directly led to the resident's fall and injury. The deficiency was identified through interviews, document review, and progress notes, which all confirmed the deviation from the prescribed transfer protocol.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to implement proper infection prevention and control practices, specifically regarding Enhanced Barrier Precautions (EBP) and hand hygiene, during direct care for residents identified as requiring these measures. Observations revealed that three staff members, including nursing assistants and a physical therapist, did not consistently wear gowns and gloves as required during high-contact care activities for residents with wounds or other risk factors for multi-drug-resistant organisms. For example, during a transfer and linen change for a resident with cellulitis, lymphedema, and wounds, staff wore gloves but not gowns, and did not always change gloves or perform hand hygiene between tasks. Another resident with wounds and a history of falls was observed during room tidying and linen changes, where staff did not wear gloves or gowns as indicated by EBP signage and care plans. Staff were seen handling soiled linens, resident equipment, and personal items without appropriate PPE or hand hygiene. Interviews with staff revealed inconsistent understanding and application of EBP protocols, with some staff acknowledging lapses or uncertainty about when gowns and gloves were required. The facility's policy and care plans directed the use of EBP, including gowns and gloves, during high-contact activities such as dressing, bathing, transferring, and changing linens. However, documentation and staff interviews indicated that these protocols were not consistently followed, and order sets for residents requiring EBP lacked specific orders. The infection preventionist and nurse manager confirmed the expectations for EBP use, but observations and staff statements demonstrated gaps in adherence to infection control procedures.
Failure to Prevent Allergic Reaction Due to Inadequate Allergy Management
Penalty
Summary
The facility failed to ensure that a resident with a known severe allergy to ginger received a meal that accommodated this allergy. The resident, who was cognitively intact and required setup assistance for eating, was served a meal containing honey ginger chicken, which led to an anaphylactic reaction. Despite having an order for epinephrine to be used in such cases, the resident was not administered the medication because it was on hold due to insurance issues, and the staff did not have it available in the emergency medication kit. The resident's care plan and dietary communication indicated allergies to ginger and bee pollen, but this information was not accurately reflected in the nutrition program used by the dietary staff. The meal tray ticket for the resident did not list any food allergies, and the dietary staff failed to verify the meal contents against the resident's allergy information. This oversight resulted in the resident consuming the allergen and experiencing a severe allergic reaction, necessitating emergency medical intervention. Interviews with facility staff revealed a breakdown in communication and procedure adherence. Dietary staff were expected to enter and verify allergy information in the nutrition program, which should have prevented the ordering of allergenic foods. However, the system did not flag the ginger allergy, and the meal tray ticket did not display this critical information. Additionally, the facility's emergency preparedness was inadequate, as the necessary medication for anaphylaxis was not readily available, highlighting a significant lapse in ensuring resident safety.
Removal Plan
- Conduct a whole house audit by nutrition services to verify all residents' allergies listed in the medical record are accurately listed in the nutrition system and that those allergies accurately print on the residents' meal tray ticket.
- Implement a process to ensure residents receive appropriate food items and not receive identified food allergens.
- Ensure meal service observation identifies staff confirm the meal served matches the meal tray ticket and any food allergies listed on the meal ticket are not served.
- Ensure R23's orders and stocked medication include epinephrine.
- Review E-kit contents to ensure inclusion of epinephrine.
- Start nutrition staff education on allergy information communication and entry into the nutrition system, meal service, meal ticket and allergy review, and tray assembly.
- Start nursing staff education on verification that the meal delivered matches the tray ticket and does not contain any food allergens.
- Include nursing education on E-kit contents, use of epinephrine via a vial, standing house orders, signs and symptoms of anaphylactic reaction, procedure for allergic and anaphylactic reactions, and incident reporting.
- Educate all staff prior to their next shift.
- Continue compliance monitored via meal service audits.
- Review audit results by the quality committee.
Failure to Document Vaccination Offers and Decisions
Penalty
Summary
The facility failed to ensure that four residents were offered and/or provided updated vaccinations for pneumococcal disease, and two residents for influenza, in accordance with CDC guidelines. The residents involved had various medical conditions that increased their risk for pneumococcal diseases, such as diabetes and hepatic encephalopathy. Despite having received previous vaccinations, the facility did not document discussions of shared clinical decision-making regarding additional pneumococcal vaccines, nor did they document declinations or discussions of risks and benefits for these vaccinations. Resident 15, who had diabetes, had received previous pneumococcal vaccines but lacked documentation of further discussions or decisions regarding additional vaccinations. Similarly, Resident 33, also with diabetes, had up-to-date pneumococcal vaccinations but lacked documentation of shared decision-making for further vaccinations and had not received an influenza vaccine since 2020. Resident 54, with a history of intracerebral hemorrhage, also had complete pneumococcal vaccinations but lacked documentation of further discussions or decisions. Resident 110, with moderately impaired cognition and liver conditions, had outdated pneumococcal and influenza vaccinations and lacked documentation of discussions or decisions regarding additional vaccinations. The facility's infection preventionist and director of nursing confirmed the lack of documentation for these residents. The facility's policy required offering vaccinations and documenting refusals and discussions of risks and benefits, but these procedures were not followed. The infection preventionist stated that the process involved printing immunization reports, offering vaccines, and documenting refusals, but this was not consistently done for the residents in question.
Failure to Maintain Resident Dignity During Care
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as R35, during personal care activities. R35, who has dementia and is dependent on staff for toileting and personal hygiene, was observed during evening care being assisted by two nursing assistants (NA-C and NA-D) using a mechanical body lift. During the process, R35 was left completely nude and exposed on the bed while the nursing assistants attended to her hygiene needs. Despite R35's repeated verbal protests, the staff continued with the care without adequately covering her, leaving her exposed to the open door when a registered nurse (RN-C) entered the room. RN-C attempted to cover R35 with a hospital gown, acknowledging the importance of maintaining dignity by covering residents during care. Interviews with the staff, including NA-C, RN-D, and the Director of Nursing (DON), revealed an expectation to maintain resident dignity by covering them during care and ensuring privacy. However, the staff involved admitted to not considering the resident's dignity during the care process. The facility's policy on dignity was requested but not provided, indicating a potential gap in policy adherence or availability. The incident highlights a deficiency in maintaining resident dignity during personal care, as observed and reported by the surveyors.
Failure to Complete Self-Administration Assessment for Resident
Penalty
Summary
The facility failed to ensure a self-administration of medications assessment was completed for a resident, identified as R44, who was observed with medications at his bedside. R44 had intact cognition but was dependent on staff for personal hygiene and mobility, and required assistance with eating. His medical history included a stroke, aphasia, dementia, and hemiplegia or hemiparesis. Despite these conditions, there was no documentation in his records of an order for self-administration of medications or an assessment to determine his ability to self-administer. Observations over several days noted a bottle of Tums on his bedside table, which was confirmed by nursing staff to have been brought by his family. Interviews with nursing staff, including an RN and an LPN, revealed that the facility's policy required a self-administration assessment and a provider's order for a resident to self-administer medications. However, these steps were not completed for R44. The staff acknowledged the oversight and expressed concerns about the potential risks of medication interactions and the need for provider involvement. The facility's policy also stated that medications should be removed from a resident's room if found without proper authorization, which was not done in this case.
Failure to Notify Physician and Follow Wound Care Orders
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident with congestive heart failure (CHF) who experienced substantial weight gain. The resident's care plan required daily weights and notification to the provider if there was a weight gain of more than 2 pounds in one day or 5 pounds in one week. Despite the resident's weight increasing by 11.4 pounds in one week and 8.8 pounds in one day, there was no documentation indicating that the physician was informed of these changes. Interviews with nursing staff confirmed that the physician should have been notified, and the lack of notification was acknowledged by the director of nursing. Additionally, the facility failed to follow appropriate wound care orders for a resident with moisture-associated skin damage (MASD). The resident's care plan required specific wound care treatments, including cleansing with a wound cleanser and covering with a Mepilex dressing. However, during an observation, a nurse applied Medihoney, which was not part of the prescribed treatment for the resident's buttocks. The nurse was unable to find current wound treatment orders and mistakenly applied the treatment intended for a different wound on the resident's heel. The facility's policies required staff to document weight changes and notify the provider as needed, as well as to verify treatment orders before administering care. The director of nursing confirmed that staff were expected to review treatment orders if unsure and to report any changes in condition to the provider. The failure to adhere to these protocols resulted in deficiencies in both notifying the physician of the resident's weight gain and in following the prescribed wound care orders.
Failure to Provide Adaptive Equipment for Resident with Dysphasia
Penalty
Summary
The facility failed to ensure that adaptive equipment, specifically a nosey cup, was consistently provided and used for a resident with cognitive impairment, dementia, stroke, and dysphasia. The resident required a mechanically altered diet and honey thick liquids, as indicated in their care plan and meal tickets. Observations on two separate occasions revealed that the resident's meal trays did not include the necessary nosey cup, and nursing assistants assisted the resident with a normal cup instead. This was despite the meal tickets clearly indicating the need for a nosey cup. Interviews with staff, including nursing assistants, dietary aides, the kitchen manager, a registered nurse, and the Director of Nursing, confirmed that the adaptive equipment was expected to be provided by the dietary staff and used by the nursing staff. However, there was a lack of communication and follow-through when the nosey cup was not included on the meal tray. The facility's policy on adaptive equipment required staff to ensure residents were provided with the necessary special equipment to reach their highest level of functioning, which was not adhered to in this case.
Inadequate Hand Hygiene and Infection Control Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene and infection control practices during the care of two residents. One resident, who had cognitive impairment and was diagnosed with dementia and heart failure, was observed in a room where a nursing assistant (NA) did not perform hand hygiene or change gloves after handling soiled items and before assisting the resident with personal care tasks. The NA used soapy water from a commode bucket to clean the floor, which was not an appropriate disinfectant, and did not notify environmental services to properly sanitize the area. Another resident, who had cognitive impairment and was diagnosed with dementia, stroke, and dysphagia, was dependent on staff for toileting and bed mobility. During care, a nursing assistant did not change gloves or perform hand hygiene after handling a soiled brief and before assisting with clean tasks. The soiled brief was placed on the floor instead of being disposed of immediately, and hand hygiene was only performed after the care was completed and the garbage was taken to the utility room. Interviews with staff, including the infection preventionist and the Director of Nursing, confirmed that the expected procedures for hand hygiene and glove exchange were not followed. The facility's policy on environmental cleaning did not outline procedures for cleaning bodily fluids, and a policy for hand hygiene was not provided. These lapses in infection control practices were observed and verified by the surveyors, indicating a deficiency in the facility's infection prevention and control program.
Failure to Timely Report Anaphylactic Reaction
Penalty
Summary
The facility failed to report an incident of potential harm to the State Agency within the required timeframe. A resident, who was cognitively intact and had known food allergies to ginger and bee pollen, experienced an anaphylactic reaction after consuming a meal that contained ginger. Despite the resident's inquiries to staff about the presence of ginger in the meal, they were incorrectly informed that it was not present. The resident's epinephrine order was on hold due to insurance issues, and the medication was not available in the emergency kit, leading to the resident being sent to the hospital for treatment. The facility's risk management records lacked evidence of an investigation or safety incident report for the anaphylactic event. Interviews with the Director of Nursing (DON) and the administrator revealed that the incident was not reported to the State Agency until over two months later. Facility policies required immediate reporting of such incidents and initiation of an internal investigation, which did not occur in this case. The failure to report and investigate the incident in a timely manner constitutes a deficiency in the facility's compliance with state and federal regulations.
Failure to Investigate Anaphylactic Reaction Incident
Penalty
Summary
The facility failed to investigate an incident involving a resident who experienced an anaphylactic reaction after consuming a meal that contained ginger, a known allergen for the resident. The resident, who was cognitively intact and required setup assistance for eating, had a documented allergy to ginger and bee pollen. Despite this, the resident was served a meal of Honey Ginger chicken thighs and Asian Stir fry vegetables, which led to the allergic reaction. The resident reported the reaction to staff and requested epinephrine, but was informed that the epinephrine order was on hold due to insurance issues and was not available in the emergency medication kit. Consequently, the resident was sent to the hospital after staff called 911. The facility's risk management records lacked evidence of an investigation or safety incident report following the resident's anaphylactic reaction. Interviews with the Director of Nursing (DON) and the administrator revealed that the event was not reported to the State Agency (SA) until over two months later. The facility's policies required immediate reporting and investigation of such incidents, but these procedures were not followed. The failure to initiate a safety event or risk management entry, as well as the delay in reporting to the SA, contributed to the deficiency identified by the surveyors.
Failure to Prevent Falls During Resident Transportation
Penalty
Summary
The facility failed to determine causal factors and develop new interventions to prevent falls for a resident with a history of falls. The resident, who had dementia, schizophrenia, and moderate cognitive impairment, was using a wheelchair for mobility and was unable to ambulate. Despite being at risk for falls due to deconditioning, balance problems, incontinence, psychoactive drug use, and a history of falls, the facility did not adequately address these risks. The resident's care plan included verbal reminders and offering to lie down when restless, but these measures were insufficient to prevent the incident. The incident occurred when the resident slid out of her wheelchair while being transported to an appointment. The transportation driver reported that the resident could not stay in the wheelchair and was sitting on the floor of the van for 10 minutes before returning to the facility. The facility's documentation lacked a post-fall assessment to identify the cause of the fall and update interventions to prevent future occurrences. Interviews with staff revealed that the resident frequently attempted to slide out of her wheelchair, and it was suggested that a reclining wheelchair would have been safer for transportation. The facility's director of nursing was not informed of the resident's risk of sliding out of her wheelchair, indicating a communication breakdown among staff. The transportation company owner expressed concern about the resident being sent alone with just the driver, suggesting that a staff member or a stretcher should accompany the resident in the future. The facility's policy on fall risk and post-fall investigation was not effectively implemented, leading to the deficiency in preventing falls for this resident.
Inadequate Supervision Leads to Resident's Hospitalization
Penalty
Summary
The facility failed to provide adequate supervision when a family member took a resident, who had impaired cognition and was an elopement and fall risk, into the community where the resident subsequently fell and was hospitalized. The resident's care plan and electronic health record (EHR) included instructions that the resident was not to go on outings or leave of absence with family due to previous incidents involving the family member. Despite these instructions, a nurse mistakenly allowed the family member to take the resident out of the facility, leading to the resident fainting at a train station and being transported to the hospital for a possible stroke. Interviews with staff revealed a lack of awareness and communication regarding the resident's restrictions. A registered nurse and a nursing assistant confirmed that the family member was allowed to take the resident out after verifying the family member's identity, despite previous instructions to the contrary. The director of nursing acknowledged that staff were initially cautious due to warnings from hospital staff about the family member, but the resident's WanderGuard alarm was removed as the resident was not exit-seeking. The facility did not provide a policy on allowing visitors to take residents out of the building when requested.
Medication Errors Affect Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. One resident, with severely impaired cognition and diagnoses of dementia and depression, was admitted with a hospital discharge order for vortioxetine, an antidepressant. However, the medication was not administered for over a month, as it was not transcribed into the electronic health record. This oversight was discovered by the consulting pharmacist, and the facility reported the error to the State Agency. Another resident, with moderately impaired cognition and diagnoses of depression, anxiety, and psychosis, was prescribed Abilify for hallucinations. The medication was initially administered but was discontinued prematurely due to a transcription error. The resident experienced a resurgence of hallucinations, which were distressing and led to physical harm from scratching. The error was identified when the nurse practitioner reviewed the medication list and found that the scheduled Abilify had been discontinued instead of just the PRN order. The facility's transcription process was flawed, as orders were not consistently double-checked, and there was no procedure for following up with providers on time-limited medication orders. The Director of Nursing acknowledged that the transcription errors occurred because the orders were not properly verified and uploaded into the electronic system. The facility's policy required orders to be double-checked and signed off, but this was not adhered to, leading to significant medication errors for the residents involved.
Failure to Ensure Proper Handwashing and Glove Usage
Penalty
Summary
The facility failed to ensure proper handwashing and glove usage during personal care for a resident. During an observation, a nursing assistant (NA) was seen changing a resident's brief and then performing multiple tasks without removing her gloves or washing her hands. These tasks included changing the resident's shirt, adjusting the bed, and handling the bed controller. The NA only removed her gloves and used hand sanitizer after leaving the resident's room and disposing of the soiled shirt in the utility room. Interviews with the NA, the Infection Preventionist (IP), and the Director of Nursing (DON) confirmed that the NA did not follow proper infection control protocols. The IP and DON both stated that staff should always remove gloves and wash or sanitize their hands after providing peri care and before moving on to other tasks. The facility's policy on handwashing and glove usage did not address the specific requirements for changing gloves and washing hands during resident care.
Improper Fit of Air Mattress on Bed Frame
Penalty
Summary
The facility failed to ensure a pressure relief air mattress was assessed for safe size in relation to the bed frame and grab bars for a resident. The resident, who was cognitively intact and had diagnoses including sepsis, muscle weakness, and encephalopathy, required substantial assistance for bed mobility and was at risk for pressure ulcers. The resident's care plan included the use of a pressure-reducing device for their bed, but the air mattress provided did not fit the bed frame properly, creating significant gaps between the mattress and the grab bars, which posed a risk of entrapment and injury. Observations revealed that the air mattress could move freely on the bed frame, resulting in gaps of up to eight inches between the mattress and the grab bars. Despite the resident's use of the grab bars for repositioning, staff often placed pillows in the gaps, which was not a sufficient or safe solution. Interviews with staff confirmed that the mattress and bed frame were incompatible, and the issue had not been identified or addressed appropriately. The facility's policies and manufacturer guidelines clearly indicated that mattresses must fit snugly against the bed frame to prevent entrapment. However, the staff failed to ensure the proper fit of the mattress, and the issue was not communicated or rectified by the vendor who delivered the mattress. This oversight led to a situation where the resident was at risk of entrapment and injury due to the improper fit of the air mattress on the bed frame.
Failure to Coordinate Hospice Services
Penalty
Summary
The facility failed to ensure proper coordination of services between the facility and the hospice agency for a resident with severe cognitive impairment and schizoaffective disorder, bipolar type. The resident's medical record lacked essential hospice documentation, including current contact information for hospice staff, a current medication list, a care plan, goals for care, hospice certification and recertifications, the hospice election form, and hospice orders. Additionally, there was no schedule for hospice visits for March 2024, and the most recent visit note by a hospice nurse was dated over a month prior, on 2/2/24. Interviews with facility staff revealed ongoing coordination issues with the hospice agency, such as unanswered emails, incomplete forms, and incorrect contact information for hospice team members. The social worker and director of nursing both confirmed that the resident's chart should have contained comprehensive hospice documentation and a visit schedule. The hospice director acknowledged the deficiencies, including missing care plans, outdated provider information, and a lack of documented visits by nursing assistants in February. The facility's hospice contract and policy both outlined the need for coordinated care and timely documentation, which were not met in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,051 citations issued within 25 miles in the last 12 months — including the 34 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Capitol View Transitional Care Center | 0.5 mi | ★★★★★ | 1 | 0 |
| Little Sisters Of The Poor | 0.6 mi | ★★★★★ | 5 | 0 |
| The Villas At St Paul | 0.7 mi | ★★★★★ | 3 | 0 |
| The Emeralds At St Paul Llc | 0.9 mi | ★★★★★ | 0 | 0 |
| Cerenity Care Center On Humboldt | 1.5 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.