Below 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 Episcopal Church Home The Gardens during CMS and state inspections, most recent first.
Improper food storage and labeling were found in 6 of 6 kitchenette areas, with multiple opened frozen items left undated and unsealed, including bacon, waffles, french toast, omelets, and other foods. In one kitchenette, surveyors also found an undated bowl of noodles, an undated container of beans, and expired opened carrots. The CM and NA staff verified the items should have been sealed, dated, and labeled, and the ADM stated opened items were expected to be handled and stored properly.
A facility failed to ensure proper glove use and hand hygiene during personal care for a resident who was incontinent and dependent on staff. It also failed to use EBP for a resident with a nephrostomy tube and another resident with a catheter during high-contact care, despite door signage and staff acknowledgment that gowns and gloves were required. In addition, a resident on droplet precautions was observed in therapy and moving through the facility without a mask, and the PT was also not wearing the required protection.
A resident with MS, COPD, arthritis, and documented functional and cognitive decline had a nasal spray at the bedside even though the SAM assessment said the resident had no desire to self-administer and the IDT did not feel the resident was safe for SAM. The resident could not reliably recall which nasal spray was used, staff gave conflicting accounts about SAM status, and the DON stated the resident should not have any medications left at the bedside.
Failure to maintain privacy during personal care: A resident with intact cognition, urinary and bowel incontinence, and dependence for toileting and hygiene was observed during a brief change with the room door left open to the hallway. The NA left the resident exposed while getting supplies, and a PT knocked once on the open door and entered without waiting, seeing the resident’s exposed bottom. The resident said the door should have been shut, and RN, LPN, and DON interviews confirmed doors should be closed during personal cares.
A resident with chronic respiratory failure with hypoxia and COPD did not receive oxygen therapy as ordered. Staff found the nasal cannula off or improperly positioned, the concentrator set below the ordered flow rate, and the tubing unlabeled for when it was last changed. NAs did not address the incorrect oxygen setup, and an NA later adjusted the flow rate after confirming it was set incorrectly.
Pharmacy recommendations were not addressed timely for a resident with moderate cognitive impairment, chronic pain syndrome, constipation, and opioid use. The consultant pharmacist repeatedly identified duplicate PRN constipation meds, MiraLAX and docusate, and asked for parameters or discontinuation of one, but the MARs still listed both without instructions on which to give first. The DON and CP both stated the review should have been addressed sooner.
Improper Crushing of Delayed Release and Capsule Medications: A medication assistant crushed delayed release tablets and a capsule medication for a resident with severe cognitive impairment, dysphagia, and multiple chronic conditions instead of opening the capsule and emptying the contents. The assistant stated she usually crushes capsules because they are hard to take apart while wearing gloves, despite prior education on delayed release medications. The pharmacist, RN, and DON all stated capsules should be opened rather than crushed, and facility policy said timed release and enteric coated medications should not be crushed.
A deficiency was cited when a resident's right to a dignified existence, self-determination, communication, and the exercise of their rights was not upheld by the facility.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to resident safety.
A bed rail was used without first attempting alternative interventions, assessing the resident for safety risk, reviewing risks and benefits with the resident or representative, or obtaining informed consent. The facility also failed to ensure the bed rail was correctly installed and maintained.
A resident was not protected from a significant medication error, as required, due to a failure in the medication administration process.
A resident was not provided with hospice services, nor was assistance given to transfer the resident to a facility that could arrange for hospice care, resulting in a deficiency related to the provision of end-of-life services.
The facility did not regularly inspect bed frames, mattresses, and bed rails for safety, and failed to ensure that bed rails and mattresses were safely attached to the bed frame as required.
A resident with significant cognitive and physical impairments reported to multiple staff that she experienced rough handling and yelling from staff, causing her pain and distress. Several staff were aware of these allegations, with some reporting to supervisors and others not reporting at all. One staff member reported the incident to the state agency independently, but not on behalf of the facility. The facility's required immediate reporting and investigation procedures were not followed, and the grievance log contained no record of the complaints.
A resident with Parkinson's disease, dementia, and kidney disease experienced multiple falls, and although new interventions were identified after each incident, these were not consistently added to the care plan or communicated to staff. As a result, important safety measures such as frequent checks and the use of a fall mat were not reliably implemented, leading to gaps in care.
A resident with multiple chronic conditions had a skin tear on the right forearm that was not consistently assessed or treated after initial physician orders were discontinued. Staff interviews and documentation review revealed that the wound was not monitored or addressed according to facility policy, and weekly skin checks were not performed as required.
The facility failed to monitor refrigerator, dishwasher, and breakfast food temperatures across six unit kitchens, leading to undated and potentially unsafe food consumption. Observations revealed missing or incomplete temperature logs, and interviews highlighted confusion among staff about monitoring responsibilities. A resident reported sour-tasting milk, underscoring the issue. The RD acknowledged the need for training nursing assistants on temperature monitoring and the importance of dating opened food containers.
The facility failed to follow proper infection control practices, as observed when a nursing assistant did not change gloves after providing peri-care to a resident and continued to assist with dressing and transfers. Additionally, a standing lift sling shared by residents was not sanitized between uses, contrary to facility policy. These actions were confirmed as infection control issues by an LPN.
A resident with a history of coronary artery disease and skin conditions had a PRN order for Nystatin powder, which was improperly administered by a nursing assistant. The NA applied the medication without authorization, as only nurses are permitted to assess and document PRN medication needs. The facility's policy on medication administration was not provided.
Two residents in a facility were not provided adequate assistance with personal hygiene, specifically shaving, despite their dependence on staff for such care. One resident with severe cognitive impairment was observed with long facial hair, which she disliked, while another resident, who preferred to be clean-shaven, was found with a full-face beard. Staff interviews revealed inconsistencies in offering shaving assistance, contrary to the facility's policy on maintaining cleanliness and grooming.
A resident with severe cognitive impairment and multiple medical conditions was observed leaning to the right in various chairs without staff intervention to reposition her. Despite being dependent on staff for daily activities and having a history of falls, her care plan lacked interventions for positioning. Staff were aware of her tendency to lean but did not take action to address it, contrary to the facility's policy of providing necessary care.
A facility failed to consistently monitor orthostatic blood pressures for a resident on antipsychotic medication, despite physician orders and facility policy requiring monthly checks. The resident, with a history of dementia and bipolar disorder, was at increased risk of falls due to potential side effects of the medication. Staff interviews confirmed the importance of these checks but revealed incomplete documentation without any noted refusals by the resident.
A resident's medication cabinet was found open and unsecured, containing multiple medications and a glucometer, while the resident was not in the room. A nurse admitted to leaving the cabinet open after being distracted, acknowledging the need for it to be locked to prevent unauthorized access. The facility's policy requires medication cabinets to be locked to ensure safe storage and administration.
Two residents at a long-term care facility experienced repeated falls due to the facility's failure to update and implement effective fall prevention strategies. One resident, with severe cognitive impairment and multiple medical conditions, had 20 falls without new interventions being added to her care plan. Another resident, who was independent with mobility, also experienced multiple falls with injuries, but her care plan was only updated once. Staff interviews revealed inconsistencies in applying fall interventions and conducting necessary assessments.
Improper Food Storage and Labeling in Multiple Kitchenettes
Penalty
Summary
The facility failed to ensure foods were stored in a manner to prevent spoilage and freezer burn, and failed to ensure food items in 6 of 6 kitchenettes were sealed, labeled, and dated. During observations of the 2nd, 3rd, 4th, 5th, 6th, and 7th floor kitchenettes, surveyors found multiple undated, opened frozen food items, including bacon, pancakes, waffles, french toast, hot dog buns, pepperoni, english muffins, omelets, corn dogs, sausages, bagels, meat patties, and burgers. Staff members present in the kitchenettes verified that the items should have been sealed, dated, and labeled. In the 4th floor kitchenette, surveyors also observed an undated bowl of noodles, an undated Tupperware container of beans, and an opened bag of carrots that had expired on 3/25/26. The chef manager stated that opened food items were expected to be sealed, dated, and labeled, and that the kitchenettes had Ziplock bags, markers, and deli containers with lids available for storage use. The administrator stated that all staff were expected to handle and store food properly and that opened items were to be labeled, dated, and sealed. A facility policy titled Episcopal Homes Refrigerator and Food Storage directed staff to ensure opened freezer foods were sealed to prevent freezer burn and spoilage, and that all foods must be sealed, labeled, and dated.
Infection Control Failures With Glove Use, Enhanced Barrier Precautions, and Droplet Precautions
Penalty
Summary
The facility failed to ensure appropriate glove use and hand hygiene during personal care for a resident who was dependent on staff for toileting and personal hygiene and was frequently incontinent of bowel and urine. During observation, a nursing assistant donned gloves, removed a brief soiled with bowel movement, and completed peri care, but then continued the care without changing gloves, including placing a new brief, pulling the gown down, repositioning the resident’s legs by grasping the feet, and adjusting the bed. The nursing assistant stated she did not change gloves after cleaning the bowel movement and was not aware she needed to do so. Other staff stated gloves should be removed and hand hygiene completed after peri care and before moving to other resident care. The facility also failed to implement enhanced barrier precautions for the same resident who had a nephrostomy tube. The resident’s record identified the nephrostomy tube and the care plan instructed staff to perform nephrostomy tube care as ordered. Observations showed the resident’s doorway initially lacked signage for infection control precautions, and the resident’s nephrostomy bag was visible and lying on top of the sheet. During personal care, a nursing assistant entered the room wearing gloves but not a gown and performed a brief change, peri care, and repositioning without using enhanced barrier precautions. Later, a sign and isolation cart were present, and the sign directed staff to perform hand hygiene and don gloves and gown when entering for high-contact resident care activities. Staff stated the resident should have been on enhanced barrier precautions because of the nephrostomy tube and that gown and gloves should be used for nephrostomy care and other high-contact care. The facility further failed to ensure enhanced barrier precautions were used for another resident with an indwelling catheter who was receiving catheter care. During observation, a nursing assistant emptied the catheter bag into a graduated cylinder and then into the toilet while wearing gloves but not a gown, despite the door sign indicating a gown should be worn for catheter cares. The nursing assistant verified the resident was on enhanced barrier precautions and stated the gown should have been worn but was forgotten. The facility also failed to ensure a resident on droplet precautions wore a mask when out of the room. The resident had respiratory symptoms and was placed on droplet precautions, with a sign at the door directing that the resident wear a mask when leaving the room and that staff use eye protection and appropriate face covering. During observation, the resident was in the therapy room and later moved through the facility without a mask or eye protection, and the physical therapist was also not wearing the required protection. Staff later provided masks, and staff interviews confirmed the resident and therapist had not been following the posted droplet precaution directions.
Unsafe Self-Administration of Bedside Medication
Penalty
Summary
The facility failed to ensure that a resident was safe for self-administration of medication when the resident had a nasal spray at the bedside despite a recent self-administration assessment indicating the resident had no desire to self-administer and that the interdisciplinary team did not feel the resident was safe for self-administration. The resident’s record showed intact cognition on the quarterly MDS, but also documented multiple sclerosis, COPD, arthritis, need for assistance with personal care, and a care plan revised to reflect inability to manage self-care related to functional and cognitive decline. The care plan stated the resident wanted to be involved in care and medications, but also directed staff to administer medications as ordered and did not include specific information about self-administration. Provider orders included an older order stating the resident was okay to self-administer medications after set-up, along with orders for Ipratropium Bromide nasal spray and Fluticasone Propionate nasal spray. The MAR did not indicate the Ipratropium Bromide spray could be left at the bedside or self-administered, and the Fluticasone Propionate spray was documented as administered by staff on multiple days. During observation, an LPN gathered the resident’s morning medications, and the resident stated she had already used the Ipratropium Bromide spray at her bedside and sometimes used it again in the afternoon if needed. The resident was initially unaware of the second nasal spray stored in a locked in-room medicine cabinet and could not recall whether she had used it that morning. Staff interviews showed conflicting understanding of the resident’s status, with one LPN stating the resident had been assessed as appropriate for self-administration and another LPN and the DON stating the resident was not appropriate and should not have medications left at the bedside.
Failure to Maintain Privacy During Personal Care
Penalty
Summary
The facility failed to ensure personal privacy was maintained for one resident who was observed during personal care. The resident’s annual MDS indicated intact cognition, dependence on staff for toileting and personal hygiene, and that the resident was always incontinent of urine and frequently incontinent of bowel. The resident’s diagnoses included chronic kidney disease, anxiety, and need for assistance with personal care. The care plan revised 4/6/26 stated the resident required assistance of one for personal hygiene and substantial to total assistance for toileting. During observation on 4/7/26 at 10:05 a.m., a NA entered the resident’s room to provide a brief change and did not close the door, which remained open to the hallway. The NA lowered the head of the bed, lifted the resident’s gown, removed the brief, and went into the bathroom to get a new brief while the resident waited exposed from mid-abdomen down. While the NA was wiping the resident’s bottom, a PT knocked once on the open door, entered without waiting for a response, and saw the resident’s exposed bottom before leaving. The NA stated she should have closed the door, and the resident stated she wished the door had been shut during peri care and wondered why the PT had walked in. RN, LPN, and DON interviews stated resident doors should be closed during personal cares to protect privacy, and the facility policy stated residents are provided privacy during personal care and staff will knock and request permission before entering resident rooms whenever possible.
Oxygen Therapy Not Maintained as Ordered
Penalty
Summary
The facility failed to ensure oxygen therapy was administered and maintained as ordered for a resident with chronic respiratory failure with hypoxia, COPD, anxiety, and dyspnea. The resident’s provider ordered oxygen via nasal cannula at 4 liters per minute continuously for dyspnea, with tubing and cannula/mask to be changed and dated weekly. The resident’s care plan also stated that oxygen saturations would drop into the 80s when oxygen was removed and instructed staff to administer oxygen as ordered. During observation, the resident was found with the oxygen tubing wrapped up and hanging off the concentrator out of reach, the concentrator set at 3 lpm instead of the ordered 4 lpm, and the nasal cannula positioned on the chin rather than in the nares. The tubing was not labeled to show when it had last been changed. Staff observed the resident without addressing the oxygen tubing or flow rate, and the resident stated she took the oxygen off for breakfast and would replace it afterward. Later, an NA confirmed the flow rate was set at 3 lpm and changed it to 4 lpm. RN, LPN, and DON interviews confirmed the ordered flow rate should have been maintained, tubing should have been labeled and dated, and NAs should not adjust the oxygen flow rate but should notify a nurse when it was incorrect.
Pharmacy Recommendations Not Addressed Timely for Duplicate PRN Constipation Medications
Penalty
Summary
The facility failed to ensure pharmacy recommendations were addressed timely for one resident reviewed for unnecessary medications. The resident had moderate cognitive impairment, was frequently incontinent of bowel, and was receiving opioid medications during the lookback period. Diagnoses included adjustment disorder with mixed anxiety and depressed mood, chronic pain syndrome, and constipation. The care plan noted use of antidepressant medication and directed staff to monitor for adverse medication reactions such as constipation and fecal impaction, and also directed staff to give pain medications as ordered. The consultant pharmacy review repeatedly identified duplicate PRN constipation medications, MiraLAX and docusate, and recommended setting parameters for use or discontinuing one of them to ensure consistent administration and for state survey purposes. One review contained an undated handwritten note stating to use MiraLAX first and was signed by an unidentified nurse practitioner. Another review had an undated handwritten note that it was faxed to the provider by an LPN, and a later review noted the MAR was updated by the LPN. However, the monthly MARs from 10/2025 through 2/2026 still listed both PRN medications without any instruction as to which medication to give first for constipation. During interview, the DON stated pharmacy recommendations should have been addressed timelier, and the CP stated facilities should address reviews within about 30 days and would have expected the duplicate medications to have been addressed sooner than five months.
Improper Crushing of Delayed Release and Capsule Medications
Penalty
Summary
The facility failed to follow professional standards when a trained medication assistant crushed delayed release medications and crushed capsule medication instead of opening the capsule and emptying the contents. The resident involved had severe vascular dementia without behavioral disturbance, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, aphasia, dysphagia, epilepsy, chronic kidney disease stage 1 through 4, and depression. The resident’s MDS indicated severe cognitive impairment and dependence on staff for all activities of daily living. The resident’s MAR included orders for aspirin enteric coated delayed release, pantoprazole sodium delayed release, sertraline, divalproex sodium delayed release, acetaminophen, and a crush-medications order related to dysphagia. During observation, the medication assistant placed the medications into a plastic bag, used a pill crusher to crush all of them, and then tried to remove shredded capsule pieces from the bag. The assistant attempted to crush the medications again, and small pieces of capsule remained visible before the powder was mixed with applesauce and administered by spoon. During interview, the medication assistant stated she usually crushes capsules because it is hard to take them apart while wearing gloves, and she acknowledged the facility had provided education on delayed release medications but she could not remember what delayed release meant. Other staff and the pharmacist stated capsules should be opened rather than crushed and that delayed release medications should not be crushed. The DON stated staff had been trained on administering delayed release medications and must pass competencies. The facility policy required verification of the right medication, dose, time, and method of administration, and the crushing guidelines stated timed release tablets should not be crushed and enteric coated tablets are designed to pass through the stomach whole.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or observations involving individual residents.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Assess, Obtain Consent, and Properly Install Bed Rail
Penalty
Summary
The facility failed to try alternative approaches before using a bed rail. When a bed rail was determined to be needed, the facility did not assess the resident for safety risk, did not review the risks and benefits with the resident or their representative, and did not obtain informed consent. Additionally, the facility did not ensure the bed rail was correctly installed and maintained.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details about the actions or inactions leading to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Arrange Hospice Services
Penalty
Summary
The facility failed to arrange for the provision of hospice services for a resident or assist the resident in transferring to a facility that would provide such services. This deficiency indicates that the necessary steps were not taken to ensure the resident received appropriate hospice care as required.
Failure to Ensure Safe Attachment and Inspection of Bed Equipment
Penalty
Summary
The facility failed to regularly inspect all bed frames, mattresses, and bed rails for safety. Additionally, bed rails and mattresses were not ensured to be safely attached to the bed frame as required. This deficiency was identified through direct observation and review of facility practices regarding the maintenance and safety checks of beds and related equipment.
Failure to Immediately Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was reported immediately to the state agency and the facility administrator, as required. The resident, who had significant cognitive and physical impairments including dementia, hypovolemia, cirrhosis, and dependence on staff for daily care, reported to multiple staff members that she experienced rough handling and yelling from staff during care. She described being treated roughly by two nursing assistants, which caused her pain for several days, and stated that one staff member consistently yelled at her. The resident communicated these concerns to various staff members, but was unable to provide specific dates due to her cognitive and physical limitations. Multiple staff interviews revealed that several staff members were aware of the resident's complaints of rough care and verbal abuse. Some staff reported these concerns to their supervisors or nurse managers, while others did not report them, either because they did not witness the incidents firsthand or because they believed the resident frequently complained. One staff member reported the allegations to the state agency independently, but not on behalf of the facility, citing a lack of trust in the facility's willingness to investigate or act on such reports. The facility's grievance log did not contain any entries related to the resident's complaints during the relevant period. The nurse manager and administrator both indicated that they had not received specific reports of abuse or rough care regarding the resident, and the nurse manager admitted to not investigating rumors of possible abuse. The facility's policy required immediate reporting of suspected abuse, neglect, or mistreatment to both the facility and the state agency, but this protocol was not followed in this case. As a result, the required immediate reporting and investigation of the abuse allegation did not occur as mandated.
Failure to Update Care Plan After Multiple Falls
Penalty
Summary
The facility failed to revise and update the care plan for a resident with Parkinson's disease, dementia, and kidney disease who was at high risk for falls. Despite multiple falls and new interventions being identified in incident reports, these interventions—such as frequent visual checks, hourly safety checks, and the use of a fall mat—were not consistently incorporated into the resident's care plan or nursing assistant care sheets. Nursing staff and assistants reported that they were not given specific instructions or documentation regarding the frequency of checks, and unfamiliar staff could miss critical interventions like placing the fall mat, as it was not documented in the care plan. The resident experienced several falls over a period of time, with each incident resulting in new interventions being recommended in incident reports. However, these interventions were not systematically added to the care plan, leading to inconsistent implementation by staff. Interviews with nursing assistants and an LPN confirmed that important safety measures were omitted from the care plan, and the DON acknowledged that new interventions should have been added in a timely manner. The facility's care planning policy was requested but not provided.
Failure to Assess and Monitor Skin Tear
Penalty
Summary
The facility failed to comprehensively assess and monitor a skin tear for a resident with multiple diagnoses, including heart failure, COPD, and peripheral vascular disease. The resident had a documented skin tear on the right forearm upon admission, with an initial physician order for wound care that was discontinued after a period. Following the discontinuation, there were no further treatment orders or consistent monitoring of the wound, as evidenced by gaps in the treatment administration record and weekly skin audits that either omitted the wound or lacked detailed descriptions and measurements. Observations confirmed the presence of an open wound on the resident's right forearm, which was not being treated or monitored according to physician orders or facility policy. Interviews with nursing staff and review of documentation revealed that the wound had been present since the resident's return from the hospital, but no ongoing treatment or comprehensive assessment was in place. Nursing assistants and LPNs acknowledged the lack of treatment and inconsistent skin checks, and the DON stated that weekly skin assessments and prompt reporting of new skin concerns to the physician were expected. The facility's own skin care policy required routine and as-needed assessments and interventions to promote healing and prevent further skin problems, but these procedures were not followed for this resident.
Failure to Monitor Food and Equipment Temperatures
Penalty
Summary
The facility failed to implement a process to monitor temperatures in refrigerators, dishwashers, and breakfast foods across all six unit kitchens. This deficiency was identified through observations and interviews, revealing that temperature logs were either missing or incomplete for industrial and unit refrigerators, as well as dishwashers. The registered dietician (RD) acknowledged the absence of a kitchen manager and the transition of responsibilities from kitchen staff to nursing staff, which contributed to the lack of monitoring. The RD also noted that nursing assistants required training on proper food temperature monitoring. During observations, it was found that several unit refrigerators contained open and undated food and beverage containers, such as milk and liquid eggs, which were not labeled with dates to ensure safe consumption. This issue was highlighted when a resident reported that the milk served to them tasted sour. Interviews with nursing assistants and kitchen staff revealed confusion over who was responsible for monitoring temperatures, with discrepancies in understanding between the staff members. The RD confirmed that the expectation was for nursing assistants to monitor breakfast food temperatures and that all opened food or drink containers should be dated and discarded within seven days. The facility's policy on date marking and labeling, dated March 2016, required all food held for more than 24 hours to be labeled. However, a policy on refrigeration and dishwasher temperature monitoring was requested but not provided, indicating a gap in the facility's procedures to ensure food safety for its residents.
Infection Control Deficiencies in Glove Use and Equipment Sanitization
Penalty
Summary
The facility failed to ensure proper infection control practices during personal care for a resident identified as R35. During an observation, two nursing assistants, NA-H and NA-I, assisted R35 with personal care after the resident used a bedpan. NA-H wore gloves while providing peri-care but did not change them afterward. Instead, she continued to assist R35 with dressing and transferring to a wheelchair using the same gloves, which were potentially contaminated. NA-H acknowledged her failure to change gloves, which was confirmed as an infection control issue by the clinical coordinator, LPN-C. Additionally, the facility did not sanitize a standing lift sling shared by residents, including R35 and R9. After using the standing lift to transfer R35, NA-H cleaned the lift but not the sling, which was then used to transfer R9 without sanitization. NA-H and NA-I confirmed that while the standing lifts were sanitized after each use, the slings were not, and they were only washed weekly by the laundry. LPN-C stated that the slings should be sanitized after every use, and the failure to do so was an infection control concern. The facility's policies on standard precautions and infection control for equipment and care items were not followed. The policies required gloves to be changed after contact with body fluids and for reusable equipment to be sanitized between uses. The failure to adhere to these policies resulted in potential cross-contamination and infection control issues, as observed during the survey.
Unqualified Staff Administered PRN Medication
Penalty
Summary
The facility failed to ensure that unqualified staff did not administer as-needed (PRN) medication for a resident. The resident, who was cognitively intact, had a history of coronary artery disease, peripheral vascular disease, hypertension, and diabetes. The resident's clinical records indicated a diagnosis of local infection of the skin and irritant contact dermatitis due to fecal and urinary incontinence. The resident had a PRN order for Nystatin powder to be applied under the breast every 12 hours for a skin rash. However, the Medication Administration Record for September showed no documentation of the medication being administered. During an observation, a nursing assistant (NA) was seen applying Nystatin powder to the resident's skin, despite not being authorized to administer medicated creams or powders. The NA stated that she was instructed by nurses on how to apply the powder but acknowledged that only nurses could assess and document the need for PRN medications. Interviews with a registered nurse (RN) and a clinical coordinator/licensed practical nurse (LPN) confirmed that nursing assistants were not trained or authorized to perform assessments or administer PRN medications. The facility's policy on medication administration was requested but not provided.
Failure to Provide Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide adequate assistance with personal hygiene for two residents, R6 and R44, who were dependent on staff for activities of daily living. R6, who had severe cognitive impairment and required extensive assistance, was observed with long facial hair, which she expressed a desire to have removed. Despite the care plan indicating the need for assistance with grooming, staff interviews revealed inconsistencies in the provision of care, with some staff acknowledging the expectation to offer shaving but failing to do so consistently. R44, who had moderate cognitive impairment and was dependent on staff for personal hygiene, was observed with a full-face beard despite preferring to be clean-shaven. He reported not receiving help with shaving despite requesting it. Staff interviews indicated that shaving was typically offered on bath days, but R44's preference for being clean-shaven was not consistently respected, leading to a situation where he felt shaving was forced upon him. The facility's policy on elder rights and standard of care emphasized the need for assistance with shaving to maintain cleanliness and grooming. However, the observations and interviews highlighted a failure to adhere to this policy, resulting in neglect of personal hygiene needs for both residents. This neglect was noted as a concern for dignity, particularly for female residents, as stated by the staff.
Failure to Address Resident Positioning Needs
Penalty
Summary
The facility failed to assess and implement interventions for a resident who was unable to maintain proper positioning. The resident, who had severe cognitive impairment, Parkinson's Disease, vascular dementia, and legal blindness, was observed multiple times leaning to the right in various chairs without staff assistance to reposition her. Despite being dependent on staff for activities of daily living and having a history of falls with injury, the resident's care plan lacked interventions to address her positioning needs. During observations, staff members, including a nurse and a nursing assistant, did not attempt to reposition the resident or provide support to help her sit upright. Interviews with staff revealed an awareness of the resident's tendency to lean but no active measures were taken to address it. The nurse manager acknowledged the absence of positioning interventions in the care plan and suggested the possibility of consulting hospice for therapy assistance. The facility's policy indicated that residents should receive necessary care to maintain their wellbeing, but this was not reflected in the care provided to the resident.
Failure to Monitor Orthostatic Blood Pressures for Resident on Antipsychotics
Penalty
Summary
The facility failed to monitor orthostatic blood pressures for a resident (R51) who was prescribed antipsychotic medication, specifically Risperidone, to manage conditions such as schizoaffective disorder and bipolar disorder. The resident's medical history included dementia, bipolar disorder, anxiety, major depression, arthritis, diabetes, heart failure, and a history of falling. Despite the physician's orders for monthly orthostatic blood pressure checks, these were only documented in 5 out of 13 months since the resident's admission. Interviews with facility staff, including LPNs and an RN, revealed that the expectation was for all vital signs, including orthostatic blood pressures, to be documented in the electronic medical record (EMR). The staff acknowledged the importance of these checks due to the potential side effects of antipsychotic medications, which can alter blood pressure and increase fall risk. However, the staff could not provide a reason for the incomplete documentation and confirmed that the resident did not refuse the checks. The facility's policy on psychoactive medication, revised in 2018, required monthly orthostatic blood pressure checks for all residents receiving antipsychotic medication. Despite this policy, the checks were not consistently performed or documented for R51, indicating a failure to adhere to established protocols and potentially compromising the resident's safety.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were safely and securely stored for a resident with moderate cognitive impairment and multiple health conditions, including peripheral vascular disease, diabetes, anxiety, depression, and hyperlipidemia. The resident was dependent on staff for dressing, toileting, bathing, and transfers, but could eat independently. The resident's care plan indicated poor safety awareness and impaired cognitive function. During an observation, the medication cabinet in the resident's room was found open and unsecured, containing 19 cards of medications, about 10 lidocaine patches, and a glucometer, while the resident was not present in the room. A registered nurse admitted to leaving the cabinet open after being distracted by another resident, acknowledging that the cabinet should have been locked to prevent unauthorized access to the medications. A clinical nurse further emphasized the dangers of unsecured medication cabinets, noting that anyone could take the medications, which could be harmful if residents have allergies or difficulty swallowing. The facility's policy on medication storage requires that medication cabinets be kept locked to ensure orderly and effective medication preparation and administration, in line with infection control standards.
Failure to Implement Effective Fall Interventions
Penalty
Summary
The facility failed to implement and update appropriate fall interventions for two residents, R40 and R51, who were at high risk for falls. R40, who had severe cognitive impairment and multiple medical conditions including Parkinson's Disease and vascular dementia, experienced 20 falls since a new care plan intervention was put in place. Despite the high frequency of falls, R40's care plan lacked new interventions since February 2024, and the existing interventions were not effectively preventing falls. Observations and interviews revealed that R40 often did not have her call light within reach, and her fall interventions, such as alarms and walker placement, were inconsistently applied. R51, who had intact cognition and was independent with mobility, also experienced multiple falls with injuries, including a rib injury and a toe fracture. Despite having a history of falls and being on antipsychotic medication, R51's care plan was only updated once following a fall, and the interventions were not consistently revised to address the root causes of the falls. The facility's policy required staff to document falls, update care plans, and implement new interventions, but these actions were not consistently carried out for R51. Interviews with facility staff, including nursing assistants and a nurse manager, indicated a lack of consistent assessment and intervention following falls. Staff acknowledged that R40's fall interventions were outdated and not working, and there was a failure to conduct neuro assessments for falls involving head injuries. The facility's failure to update and implement effective fall prevention strategies for R40 and R51 resulted in repeated falls and injuries, highlighting deficiencies in the facility's fall management practices.
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.
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What surveyors actually found near you
We read the 1,050 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.
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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.
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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) |
|---|---|---|---|---|
| Episcopal Church Home Of Minnesota | 0.1 mi | ★★★★★ | 17 | 1 |
| The Estates At Lynnhurst Llc | 0.1 mi | ★★★★★ | 1 | 0 |
| St Anthony Park Home Inc | 1.8 mi | ★★★★★ | 1 | 0 |
| Lyngblomsten Care Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Hayes Residence | 2.1 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.