Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Society - Maplewood during CMS and state inspections, most recent first.
Failure to assess and monitor non-pressure skin conditions for 2 residents. One resident had a right foot wound and later a buttocks/sacrum skin issue that was initially noted without measurements and later identified as MASD with open areas of exposed dermis. Another resident had bruising above the elbow, bruising in the genital/scrotal/inner thigh area, and a surgical wound on the left lateral thigh, but the progress notes showed these non-pressure skin issues were not evaluated during the review period. Nursing and DON interviews confirmed expectations for measurement, documentation, and weekly skin monitoring, and the facility policy required documentation of skin observations and weekly monitoring of bruises, contusions, skin tears, and abrasions.
The facility failed to consistently monitor urine output, document urine characteristics, and complete/document catheter care for three residents with indwelling catheters. One resident had a recent CAUTI and later acute pyelonephritis with bilateral hydronephrosis, while another had foul-smelling, dark urine with particles and thick material in the tubing that was not documented or assessed. A third resident’s leg drainage bag was observed stored without a cap and in contact with a shower chair/curtain railing, and staff were unsure about proper bag storage and rinsing practices.
A facility failed to ensure ordered meds were available for administration for two residents. One resident missed fidaxomicin doses after a hospital return for C. diff and a catheter-associated UTI, and the MAR showed a dose was not available with no documentation that the MD was notified. Another resident’s weekly ergocalciferol was documented as not available on multiple occasions, with no record that the pharmacy or MD was notified. Staff and the interim DON verified the missing-medication documentation and expected notification and progress note entries when meds were unavailable.
Failure to Follow EBP During Catheter Care: A resident with an indwelling urinary catheter, multiple chronic conditions, and intact cognition had orders and signage directing staff to use EBPs for high-contact care. During observation, nursing assistants emptied the catheter bag wearing gloves but no gown, and one wiped the drainage port with a paper towel instead of using an alcohol swab. Staff interviews showed inconsistent understanding of when gown and glove use was required for catheter care.
The facility failed to develop comprehensive care plans for two residents who were dependent on renal dialysis. Provider orders and MDS assessments documented that each resident received dialysis at an outside center three times weekly with transportation by an outside company, and one had chronic kidney disease stage 3B. However, their care plans did not include dialysis services, goals/outcomes, interventions, or details about the dialysis center, schedule, transportation, or type of dialysis access. RNs, including those responsible for care planning, stated that such dialysis information should be in the care plan and that staff rely on the care plan to know a resident is on dialysis and where and how treatment is received, but this information was missing despite facility policy requiring care plans to address needed services and facility responsibilities.
The facility failed to provide dialysis care consistent with professional standards by not performing or documenting required pre- and post-dialysis assessments for several residents with ESRD or dependence on renal dialysis. Although care plans and orders called for monitoring of vital signs, access sites, edema, and signs of bleeding, infection, and renal insufficiency, the TARs lacked dialysis-specific monitoring, and the facility’s Clinical Monitoring–Dialysis assessments were not completed on multiple dialysis days. One resident reported that nurses did not check the access site or perform assessments before or after dialysis. Additionally, personnel files for most licensed nurses did not show dialysis-related orientation, and multiple RNs stated they had little or no training on dialysis residents and limited their checks mainly to vital signs, despite an expectation that a full dialysis assessment be completed after each treatment.
Insulin pens for multiple residents were stored together in medication carts without barriers, contrary to facility policy and manufacturer recommendations. Nursing staff and the DON were unaware that insulin pens should be separated to prevent cross-contamination, and the infection preventionist confirmed the need for separation. This practice created a risk for cross-contamination among residents requiring insulin administration.
Unpasteurized eggs were used to prepare poached and fried eggs with runny yolks for breakfast service, and about 40 residents consumed them weekly. The DM initially believed the eggs were pasteurized, but invoice review confirmed the eggs in the refrigerator were not pasteurized. A cook confirmed staff had been using the unpasteurized eggs for poached eggs with running yolks, and the DFN stated pasteurized eggs should be used when eggs are served with runny yolks per facility policy.
A resident with intact cognition had conflicting code status information in the chart, with physician orders and the PCC face sheet banner listing both DNR and attempt CPR while the POLST indicated attempt CPR. The resident stated he wanted a good faith attempt at life-saving measures and did not want DNR status. Staff gave inconsistent responses about where they would first check code status, and the DON acknowledged the conflicting information could cause a delay in CPR.
A resident with stroke, cognitive communication deficit, and quadriplegia was assessed by therapy as needing PROM to the BUEs, BLEs, and neck as part of restorative nursing after PT ended. Therapy sent communication forms directing PROM at least 3 times per week, but nursing records lacked evidence the ROM program was in place, the task report showed minimal completion, and the resident and family stated staff were not doing the exercises. During observation, staff repositioned the resident but did not perform or offer PROM, and multiple staff said they were unaware the resident was receiving restorative nursing.
The facility failed to conduct weekly skin assessments for residents at risk of pressure ulcers, affecting two residents reviewed. Despite having a performance improvement plan for high-risk pressure ulcers, the facility did not address the missing assessments. The DON highlighted the importance of documentation and noted efforts to involve a wound care company and adjust nurse schedules to prioritize assessments.
The facility failed to ensure proper PPE use and hand hygiene during a COVID-19 outbreak. Staff did not consistently wear N95 masks, gowns, or eye protection for residents on precautions, and hand hygiene was not performed between glove changes. The outbreak management was inadequate, with delays in testing and inconsistent isolation measures.
A resident with a history of heart issues experienced a malfunctioning recliner chair, which was not promptly repaired despite multiple reports. Additionally, mold was observed in the communal shower rooms, with staff acknowledging the lack of a deep cleaning schedule. These deficiencies highlight failures in maintaining a safe and clean environment.
The facility failed to conduct weekly skin assessments for three residents, leading to unmonitored skin alterations. A resident with cognitive impairment and at risk for pressure injuries did not have documented skin observations since July. Another resident with an amputation lacked documentation of wound assessments, and a third resident on anticoagulant therapy had unmonitored bruising. Staff were unaware of the origins of some skin issues, and facility policy on skin monitoring was not followed.
The facility failed to develop comprehensive care plans for two residents on psychotropic medications. One resident's care plan lacked specific plans for managing depression and monitoring medication side effects, while another's care plan did not include non-pharmacological interventions. Staff interviews confirmed these deficiencies, which were inconsistent with the facility's care planning policy.
A resident with cognitive impairment and multiple diagnoses was not provided routine incontinent care, as staff failed to check for incontinence or reposition the resident according to their care plan. Observations showed the resident was left unattended for extended periods, and interviews revealed staff were unaware of the care plan requirements. The facility's policy for incontinent care was not provided.
A resident with cognitive impairment and mobility dependence was not repositioned as required, leading to a deficiency in care. Despite a care plan mandating repositioning every two hours, staff left the resident in the same position for extended periods, increasing the risk of pressure ulcers. Observations and staff interviews revealed inconsistencies in following care plan directives and facility policies.
A resident with cognitive impairment and dysphagia was observed using straws during meals, contrary to hospital discharge orders specifying no straws. The care plan and Kardex lacked this directive, and staff were unaware of the order, assuming it was outdated. The resident had not been re-evaluated by speech therapy since hospital discharge, despite improvements. The DON expected staff to follow dietary instructions and clarify discrepancies.
A facility failed to assess a resident for bed rail safety, despite having bilateral side rails installed. Staff interviews revealed confusion about the assessment process, with some acknowledging the need for a doctor's order, consent, and a safety assessment, but uncertainty about responsibility. The facility's policy requires an assessment and inspection for entrapment risks, which were not conducted for the resident.
A consulting pharmacist failed to address the inappropriate use of the antidepressant bupropion for a resident who had undergone CABG, with no diagnosis of depression. The pharmacist's review did not include concerns about the use of bupropion, despite the facility's policy against unnecessary drugs. The Director of Nursing noted that the incorrect indication should have been identified during the initial review.
The facility failed to monitor side effects and implement non-pharmacological interventions for residents on psychotropic medications. One resident's care plan lacked non-pharmacological interventions despite being on antipsychotic medication, while another resident was not monitored for side effects of prescribed antidepressants and antipsychotics. The facility did not adhere to its policy requiring monitoring and documentation, leading to deficiencies in care planning and regulatory compliance.
A resident with multiple diagnoses, including a right foot fracture, did not receive prescribed oxycodone for pain management in a timely manner. Despite the medication being available in the facility's dispensing kit, it was not administered until the following day. The facility staff failed to obtain a passcode from the 24/7 pharmacy to access the medication, resulting in a delay.
Failure to Assess and Monitor Non-Pressure Skin Conditions
Penalty
Summary
The facility failed to assess and monitor non-pressure skin conditions for 2 residents reviewed for skin management. One resident had multiple skin issues documented across the stay, including a right foot wound requiring wound VAC therapy and later dressing changes, and a buttocks/sacrum skin issue that was first noted when the resident reported that the left butt hurt and the area appeared open. The initial note did not include measurements, and the area was later identified as moisture-associated skin damage with scabbed, fragile, dry/flaky tissue and open areas of exposed dermis. The second resident had several non-pressure skin concerns documented, including bruising above the right elbow, bruising in the genital/scrotal/inner thigh area, and a surgical wound on the left lateral thigh with sutures. The admission and skin issue assessments documented the bruises as present on admission and improving, and the surgical wound was noted with measurements not documented. However, the progress notes indicated that from the initial documentation through the end of the review period, the skin issue had not been evaluated for the genital bruising, bruising above the right elbow, and surgical wound of the left lateral thigh. During interviews, nursing staff stated they addressed skin concerns according to the treatment record and that new wounds should be measured and reported to the provider, wound team, and family. The interim DON and nurse manager stated they expected nursing to use descriptive words for new skin concerns and to obtain measurements if the skin concern was open. The DON later stated staff were expected to monitor the resident’s non-pressure skin concerns through weekly skin assessments. The facility policy directed staff to accurately document observations and assessments, and to monitor bruises, contusions, skin tears, and abrasions weekly and document changes and progress toward healing on the skin check assessment and care plan.
Inconsistent catheter monitoring, urine documentation, and catheter bag storage
Penalty
Summary
The facility failed to monitor urine output for two residents with indwelling catheters and failed to report, monitor, and document urine characteristics for one resident who was observed while staff emptied the catheter bag. One resident had intact cognition, an indwelling catheter for BPH and renal insufficiency, and a recent hospitalization for catheter-associated UTI with E. coli. Another resident had intact cognition, an indwelling catheter for BPH and urinary retention, and diagnoses including heart failure, renal failure, and a surgical wound. A third resident had moderate cognitive impairment, an indwelling catheter, neurogenic bladder, multiple sclerosis, and was dependent on staff for most ADLs. For the first resident, progress notes showed catheter care was documented only once over the review period, and the record did not show routine catheter care on other days. Urine output documentation was inconsistent, with multiple dates showing partial entries, missing totals, or no output recorded for part of the day. The resident complained that the Foley catheter had not been changed, worried about a bladder infection and hospitalization, and later had a hospital discharge summary showing acute pyelonephritis with bilateral hydronephrosis and grossly infected urine. Staff interviews indicated nursing assistants documented output and nurses reviewed it, but they could not explain shifts where no urine output was documented. For the second resident, catheter care was documented once over the review period, and urine output documentation was also inconsistent, with several shifts lacking output entries. During observation, staff emptied the catheter bag and the urine was noted to have a foul smell and darkish yellow-orange color; later, urine was observed with a yellowish hue, tannish white particles, and a thick substance in the tubing. These urine characteristics were not documented in the record, and there was no corresponding comprehensive assessment noted. Staff interviews stated urinary concerns should be reported to nursing so assessment and testing could occur, but the record did not show documentation of the observed urine findings. For the third resident, catheter care was documented only twice over the review period, and the care plan did not direct staff to complete or document catheter cares. During observation, a leg drainage bag intended for later use was stored between towels on a shower chair, with the connector port touching the shower curtain railing and no cap on the port. The bag contained clear yellow urine. Staff interviews showed uncertainty about how to store, cap, and rinse catheter bags, and the facility’s policy required catheter care in the morning and bedtime, inspection of urine characteristics, and cleaning, drying, and capping of drainage bags and tubing when stored.
Medication Not Available for Ordered Doses
Penalty
Summary
The facility failed to ensure medications were available for administration per physician order for 2 residents reviewed for medication errors. One resident was admitted back to the facility after hospitalization for clostridium difficile colitis and a catheter-associated urinary tract infection. The hospital discharge medications included fidaxomicin 200 mg by mouth twice daily for 7 days, and the hospital MAR showed a dose was given on 3/23/26 at 8:00 a.m., indicating an evening dose was also due. However, the facility physician order listed a start date of 3/24/26, and the facility MAR showed the resident did not receive the 3/23/26 evening dose and the 3/24/26 8:30 a.m. dose was marked as not available. The record did not show that the physician was notified of the missed doses or that any actions were taken regarding the unavailable medication. A second resident’s discharge medication orders included ergocalciferol 1.25 mg (50,000 units) by mouth once weekly for 12 doses for vitamin D deficiency. The MAR showed the medication was given on 4/7/26 and 4/14/26, but was documented as not available on 4/21/26, 4/28/26, and 5/5/26. The record did not show that the pharmacy or physician was notified about the missing medication. During interview, nursing staff stated that if a medication was not available they were supposed to call the pharmacy right away, and the interim DON and RN-D verified the missing medication documentation and expected nurses to document progress notes and notify the pharmacy and physician when medications were unavailable.
Failure to Follow Enhanced Barrier Precautions for Catheter Care
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBPs) and infection control measures were followed for a resident with an indwelling urinary catheter. The resident had intact cognition and required assistance with eating, personal hygiene, oral hygiene, toileting hygiene, showering, dressing, bed and wheelchair mobility, and transfers. The resident’s diagnoses included atrial fibrillation, heart failure, hypertension, benign prostatic hyperplasia, urinary tract infection, renal failure, arthritis, osteoporosis, and hip fracture. The care plan identified the catheter as related to BPH and urinary retention, and the physician order directed staff to follow EBPs because of the Foley catheter and incision. During observation, staff wore gloves but no gown when emptying urine from the catheter bag, even though the resident’s door sign directed staff to wear gloves and a gown for high-contact resident care activities, including urinary catheter care. One nursing assistant stated they only needed gowning and gloving for isolation, wounds, infections, or when nurses changed a catheter. Another nursing assistant also emptied the catheter bag with gloves and no gown, wiped the emptying port with a paper towel, and returned the port to the holder. Staff interviews showed the nursing assistants did not follow the EBP signage, while the RN manager and interim DON stated staff were expected to wear a gown and gloves when emptying urine from a catheter bag and to clean the drainage port with an alcohol swab.
Failure to Include Dialysis Services in Comprehensive Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop comprehensive care plans that included dialysis services, goals/outcomes, and interventions for two residents who were dependent on renal dialysis. For one resident, provider orders documented scheduled dialysis at an outside dialysis center three times weekly with transportation by an outside company, and the MDS identified dependence on renal dialysis and current dialysis treatment. However, the resident’s care plan did not include any information about dialysis services, goals, outcomes, or interventions, and progress notes did not specify the type of dialysis access. For the second resident, provider orders also documented thrice-weekly dialysis at an outside center with transportation by an outside company, and the MDS listed chronic kidney disease stage 3B and dependence on renal dialysis, but the care plan similarly lacked dialysis services, goals/outcomes, and interventions, and progress notes did not indicate the type of dialysis access. During interviews, multiple RNs, including those responsible for creating and revising care plans, stated that information about dialysis—such as the outside dialysis center, treatment schedule, transportation arrangements, and type of dialysis access—should be included in the resident’s care plan when a resident receives dialysis. One RN stated that staff would look to the care plan to determine where a resident receives dialysis, how the resident gets to and from the dialysis center, and what type of dialysis access the resident has, and that the purpose of the care plan is to inform staff that the resident is on dialysis and where the resident goes for treatment. Other RNs acknowledged they did not recall what type of dialysis the residents received or how they traveled to the dialysis center and indicated they would check the care plans for this information, which was not present. The facility’s care plan policy stated that the care plan would emphasize appropriate care and services and address the relationship of items or services required and facility responsibility for providing those services, but this was not carried out for the two residents receiving dialysis.
Failure to Monitor and Assess Dialysis Residents and Educate Nursing Staff
Penalty
Summary
The deficiency involves the facility’s failure to provide dialysis care and monitoring consistent with professional standards for multiple residents receiving hemodialysis at an outside provider. Three residents with end stage renal disease or dependence on renal dialysis (R1, R5, and R7) had physician orders and care plans indicating the need for ongoing dialysis and specific monitoring for complications such as bleeding, hemorrhage, bacteremia, septic shock, renal insufficiency, infection at the access site, and peripheral edema. Despite these documented needs and interventions, the treatment administration records (TARs) for these residents did not include dialysis-related ongoing monitoring before and after dialysis treatments, and the facility’s Clinical Monitoring–Dialysis UDA assessments were not completed on multiple dialysis days listed in the report. For R1, hospital records documented end stage renal disease on dialysis with a left arm AV fistula and a schedule of hemodialysis three times per week. The care plan included detailed nursing interventions to monitor and document for dialysis-related complications and to encourage attendance at scheduled dialysis appointments. However, the TAR for the period reviewed did not identify dialysis monitoring for complications, and progress notes only briefly noted that the resident was out to dialysis, without additional assessment data. The record also did not show completion of the Clinical Monitoring–Dialysis UDA on the specified dialysis date. For R5, progress notes repeatedly documented a diagnosis of dependence on renal dialysis and referenced ongoing dialysis three times per week, including multiple entries noting the resident’s return from dialysis with statements such as “no new orders,” “vital signs normal,” “denied shortness of breath,” and “no signs or symptoms of discomfort.” The care plan again listed specific monitoring interventions for edema, bleeding, infection, and renal insufficiency, and the MDS documented dependence on renal dialysis. Nonetheless, the TAR for the reviewed month did not include dialysis monitoring for complications, and the Clinical Monitoring–Dialysis UDA was not completed on numerous dialysis dates identified in the report. For R7, progress notes documented dependence on renal dialysis and multiple instances of the resident being at dialysis or returning from dialysis, with limited narrative such as noting attendance at dialysis or that there were no new orders and no complaints of pain. The care plan required monitoring and documentation for peripheral edema, bleeding, bacteremia, septic shock, renal insufficiency, infection at the access site, and depression, and the MDS recorded chronic kidney disease and dependence on renal dialysis. Despite these documented needs, the TAR did not show dialysis-related ongoing monitoring, and the Clinical Monitoring–Dialysis UDA was not completed on multiple dialysis dates. The resident reported that nurses did not check the access site before and after dialysis and did not complete an assessment upon return from dialysis. The deficiency also includes a systemic failure to ensure that licensed nurses had appropriate education to care for and assess residents receiving dialysis. Personnel records for 26 of 34 licensed nurses lacked onboarding orientation checklists identifying dialysis education. In interviews, several RNs stated they had not received training on dialysis residents or that their understanding of complications was limited to bleeding at the access site or changes in vital signs. One RN reported that after a resident returns from dialysis, she only takes vital signs and does not complete any other assessment, and another RN acknowledged that if a dialysis assessment is not present in the chart, it means it was not completed. The clinical learning and development specialist and the administrator confirmed that dialysis-specific education was not provided at the corporate level and that training, if any, was left to individual facilities, while also stating that the expectation was for nurses to complete a dialysis assessment in the chart after treatment. The absence of documented dialysis assessments and the lack of structured dialysis education for most licensed nurses contributed directly to the failure to provide dialysis services consistent with professional standards of practice.
Improper Storage of Insulin Pens Leading to Cross-Contamination Risk
Penalty
Summary
Insulin pens prescribed for multiple residents were observed to be stored together in a single plastic cup within medication carts on the transitional care unit (TCU), with no barriers separating the pens. Registered nurses reported that this method of storage had been the standard practice, with insulin pens for different residents placed together and touching, without any separation. Staff members, including RNs and the director of nursing, indicated they were unaware that insulin pens should be stored separately to prevent cross-contamination. The infection preventionist confirmed that each resident's insulin pen should be separated from others to avoid possible cross-contamination. Facility policy on insulin administration and medication storage indicated that contamination of insulin pens can occur externally, even without visible blood, and referenced the need to follow manufacturer recommendations for storage. Despite these policies, the observed practice did not align with the stated requirements, as insulin pens for different residents were stored together, creating a potential for cross-contamination.
Unpasteurized Eggs Served Undercooked
Penalty
Summary
The facility failed to ensure unpasteurized eggs were fully cooked and prepared in a manner to prevent or decrease the risk of foodborne illness. Facility invoices for multiple egg deliveries showed whole large white eggs were received, and the invoices did not indicate the eggs were pasteurized. During observation, an unopened 15-dozen box of eggs was found in a refrigerator with no marking showing the eggs were pasteurized. The dietary manager stated these eggs were used to make poached eggs and fried eggs every Thursday for residents' breakfast, and confirmed the eggs were served with runny yolks. She initially believed the eggs were pasteurized but later confirmed from the invoices that the eggs in the refrigerator were not pasteurized. The dietary manager stated the unpasteurized eggs had been used for poached and fried eggs for at least the past month, though the exact length of time could not be determined. A cook confirmed kitchen staff had been using the unpasteurized eggs to prepare poached eggs with running yolks, and that fried eggs sometimes had runny yolks as well. Approximately 40 residents consumed the poached or fried eggs on Thursdays. The director of food and nutrition, a registered dietitian, stated pasteurized eggs should be used when eggs are cooked with a runny yolk because of the risk of foodborne illness associated with undercooked unpasteurized eggs. The facility policy stated runny eggs should not be served unless prepared from pasteurized eggs.
Conflicting Advance Directive Orders in Resident Record
Penalty
Summary
The facility failed to ensure resident-specific advance directive orders were accurately reflected throughout the medical record for one resident with diagnoses of wedge compression fracture of the T11-T12 vertebra, CHF, and CKD. The resident had intact cognition on BIMS and required staff assistance with most ADLs and mobility. The resident's physician orders contained conflicting code status entries, with one order indicating DNR and another indicating attempt CPR, while the face sheet banner in PCC also showed both DNR and attempt CPR. The resident's POLST indicated to attempt CPR, and the resident stated he wanted a good faith attempt at life-saving measures if found unresponsive and said his AD should not be DNR. During interviews, nursing staff gave different answers about where they would first look for code status if the resident became unresponsive, including the POLST, the face sheet banner in PCC, or the POLST book. One RN stated the face sheet banner was confusing and could lead to error because it listed both CPR and DNR. An LPN stated she would use the face sheet banner because it was the most accurate, but later said she would seek clarification from the NP if the actual orders contained both entries. The DON also stated staff might look first in different places depending on location and acknowledged that the conflicting code status on the face sheet banner could cause a delay in CPR. The facility policy on advanced directives did not address the first place to look for a resident's code status.
Failure to Provide Ordered PROM for a Resident with Severe Mobility Impairment
Penalty
Summary
The facility failed to ensure range of motion (ROM) was completed according to therapy recommendations for a resident with cerebral infarction, cognitive communication deficit, and quadriplegia who was dependent on staff for all mobility, transfers, and ADLs. The resident’s admission MDS indicated impairment of both upper and lower extremities on both sides and no restorative nursing minutes for active or passive ROM. The care plan identified a need for restorative intervention due to limited mobility and required passive ROM to both upper and lower extremities and the neck. Therapy documentation showed the resident had reached maximum functional potential and was to transition from PT to restorative nursing for lower extremity ROM, with caregiver training completed for the family and restorative nursing staff. Additional therapy communication forms directed nursing to provide PROM for the bilateral lower extremities at least three times per week and PROM for the neck and bilateral upper extremities at least three times per week. However, the resident’s nursing care sheet lacked evidence that ROM was required, and the 30-day lookback task report showed ROM was completed one time, refused twice, and not applicable twice. During interviews, the family member and the resident indicated staff were not completing PROM. Multiple nursing and therapy staff stated they expected restorative nursing recommendations to be entered as orders or tasks and completed, but several staff were unaware that the resident was receiving restorative nursing on TCU. During observation, two nursing assistants entered the room, positioned pillows, and raised the head of bed, but PROM was not performed or offered. The DON stated PROM should have been received as part of a restorative nursing program, and facility policy stated restorative nursing recommendations from therapy were to be added to the care plan and entered into PCC for documentation.
Deficiency in Weekly Skin Assessments for Pressure Ulcer Risk
Penalty
Summary
The facility failed to ensure the effectiveness of its Quality Assessment and Assurance (QAA)/Quality Assurance Process Improvement (QAPI) committee in implementing appropriate action plans to correct quality deficiencies identified in previous surveys. Specifically, the deficiency was related to the failure to conduct weekly skin assessments for residents at risk of pressure ulcers. This issue was identified during the current survey, affecting two out of three residents reviewed for pressure ulcer risk. The facility had previously been cited for a deficiency in treatment/services to prevent/heal pressure ulcers, indicating a recurring issue with the management of pressure ulcer risks. The QAPI meeting minutes from May 2023 indicated that the facility was aware of the high risk of pressure ulcers, with a performance improvement plan in place. However, the minutes lacked evidence that the facility was addressing the missing weekly skin assessments. Interviews with the Director of Nursing (DON) revealed that while efforts were being made to address high-risk pressure ulcers, including involving a wound care company and conducting weekly interdisciplinary team meetings, the main issue was ensuring that nurses completed the necessary documentation. The DON emphasized the importance of skin assessments and noted that education had been provided, and nurse schedules had been adjusted to prioritize these assessments.
Inadequate PPE Use and Hand Hygiene During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure appropriate personal protective equipment (PPE) was donned for residents on enhanced barrier precautions (EBP) and transmission-based precautions. Observations revealed that staff did not consistently wear N95 masks, gowns, or eye protection when entering rooms of residents who tested positive for COVID-19. Some staff members wore surgical masks instead of N95 masks, citing discomfort, and others did not wear eye protection, believing it was unnecessary for certain tasks. This non-compliance with PPE protocols was observed despite clear signage indicating the required precautions. Additionally, the facility did not adhere to proper hand hygiene practices. Staff were observed failing to perform hand hygiene between glove changes during resident care activities, such as toileting and incontinence care. This lapse in hand hygiene was noted even though the facility's infection preventionist and director of nursing emphasized the importance of hand hygiene to prevent the spread of infection. The failure to perform hand hygiene was observed in multiple instances, involving different staff members and residents. The facility also did not effectively manage a COVID-19 outbreak in accordance with CDC guidance. The infection preventionist acknowledged that contact tracing was conducted, but there was a delay in testing all residents on the affected unit. The director of nursing admitted that testing for some residents was not completed promptly. The outbreak began with a resident's family member who did not disclose their COVID-19 positive status, leading to subsequent cases among residents. The facility's approach to testing and isolation was inconsistent, contributing to the spread of the virus among residents.
Deficiencies in Recliner Functionality and Shower Room Cleanliness
Penalty
Summary
The facility failed to ensure the proper functioning of reclining footrests for a resident, identified as R212, who had a history of coronary artery disease, hypertension, and recent heart surgery. The resident reported that the recliner chair's footrest would not stay elevated, which was crucial for managing her edema and swelling. Despite informing staff on multiple occasions, the issue was not addressed promptly. The maintenance manager was unaware of the problem until several days later, indicating a breakdown in communication and maintenance request procedures. Additionally, the facility did not maintain a clean communal shower room, which had the potential to affect all residents using the facility. A resident, identified as R13, reported mold growth in the shower room, which had been an issue previously but was not addressed in a timely manner. Observations confirmed the presence of dark grout, indicating mold, in the shower rooms on both the odd and even-numbered hallways. Housekeeping staff acknowledged the difficulty in cleaning the grout and the absence of a routine deep cleaning schedule. The facility's policy on maintaining a safe, clean, and comfortable environment was not adhered to, as evidenced by the lack of functional furniture and inadequate housekeeping services. The maintenance and housekeeping staff were not aware of the issues or did not have a schedule for addressing them, leading to prolonged periods without necessary repairs and cleaning. This oversight compromised the residents' right to a safe and homelike environment.
Failure to Conduct Weekly Skin Assessments
Penalty
Summary
The facility failed to ensure that weekly skin observations were completed for three residents reviewed for skin alterations. Resident 18, who had cognitive impairment and was at risk for pressure injuries, did not have documented weekly skin observations since July 25, 2024. Despite having a care plan that included interventions for pressure ulcer prevention, there was no evidence of monitoring or treatment for a skin tear on the right lower extremity until August 20, 2024. Staff were unaware of the origin of the steri-strips on Resident 18's right shin, and there was no incident report or documentation regarding the skin tear. Resident 4, who had an amputation and required wound care, also lacked documentation of weekly skin assessments for the surgical incision on the right leg. The resident's care plan and physician's orders required regular monitoring and documentation of the wound, but progress notes for July and August 2024 did not include any such assessments. A registered nurse confirmed the absence of documentation and emphasized the importance of describing the wound in progress notes for proper monitoring. Resident 12, who was on anticoagulant therapy and had a history of bruising, did not have documented weekly skin assessments since August 9, 2024. The resident reported a bruise on the upper right arm, which was not documented or monitored by staff. The bruise was attributed to the armrest of the resident's wheelchair, and the nurse manager confirmed that such skin alterations should be documented and monitored until resolved. The facility's policy required immediate notification and weekly monitoring of any skin alterations, but this was not adhered to in the cases of Residents 18, 4, and 12.
Deficiencies in Comprehensive Care Planning for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, R50 and R110, which led to deficiencies in their care. For R50, the care plan did not include specific plans for managing depression or monitoring for side effects of the psychotropic medications duloxetine and aripiprazole. Despite the resident's severe cognitive impairment and diagnoses of dementia and depression, the care plan lacked necessary details for monitoring the effects of these medications. Interviews with staff, including a consulting pharmacist and registered nurse, confirmed the absence of monitoring orders and care plan details for R50's psychotropic medication use. For R110, the care plan included the use of antipsychotic medication therapy related to bipolar disorder and psychosis but lacked non-pharmacological interventions. The resident's care area assessment indicated the use of multiple medications, including an antipsychotic, antidepressant, and hypnotic, with a history of drug-induced Parkinsonism and multiple falls. However, the care plan did not address non-pharmacological strategies to manage the resident's condition, as confirmed by interviews with the nurse manager and the director of nursing. The facility's policy on care planning emphasized the need for a comprehensive, interdisciplinary approach to meet residents' medical, nursing, and psychosocial needs. However, the care plans for both residents did not align with this policy, as they lacked measurable objectives, timeframes, and individualized interventions. The deficiencies were identified through interviews and document reviews, highlighting the facility's failure to ensure comprehensive care planning and monitoring for residents on psychotropic medications.
Failure to Provide Routine Incontinent Care
Penalty
Summary
The facility failed to provide routine incontinent care for a resident with cognitive impairment and multiple diagnoses, including heart disease, Alzheimer's Disease, and anxiety disorder. The resident was always incontinent of bladder and bowel and required maximal assistance from staff for incontinent care. Observations revealed that the resident was left unattended in their room for extended periods without being checked for incontinence or repositioned, despite being at risk for skin breakdown. Staff members, including nursing assistants and a licensed practical nurse, did not follow the care plan's instructions to check for incontinence and reposition the resident every two hours. Interviews with staff members indicated a lack of awareness and adherence to the resident's care plan, which required frequent checks and assistance with incontinence care. The nursing assistant who usually worked with the resident was not present, and the substitute staff did not perform the necessary checks or repositioning. The facility's Director of Nursing stated that incontinence care should be individualized and included in the care plan, but no specific timeframe was provided. Additionally, the facility's policy for incontinent/ADL care was requested but not received, indicating a possible lack of clear guidelines for staff to follow.
Failure to Reposition Resident at Risk for Pressure Ulcers
Penalty
Summary
The facility failed to ensure timely repositioning for a resident at risk for pressure ulcers, leading to a deficiency in care. The resident, who had cognitive impairment and was diagnosed with heart disease, Alzheimer's Disease, and anxiety disorder, was dependent on staff for mobility and at risk for pressure injury. The care plan required repositioning every two hours, use of a pressure-reducing mattress, and other interventions to prevent skin breakdown. However, observations revealed that the resident was left in the same position for extended periods without repositioning, contrary to the care plan directives. On multiple occasions, staff failed to reposition the resident as required. During one observation, the resident was left in a wheelchair for over two hours without repositioning, despite expressing discomfort. Staff interviews indicated a lack of awareness of the resident's specific needs and care plan requirements. Nursing assistants and other staff members did not consistently follow the care plan, resulting in the resident remaining in the same position for prolonged periods, increasing the risk of pressure ulcers. The facility's policy required individualized repositioning schedules for residents unable to position themselves, communicated through the Kardex. However, staff interviews and observations showed inconsistencies in following these guidelines. The Director of Nursing expected weekly skin observations and documentation of any skin alterations, but records indicated a lack of documented skin observations since a specified date. This deficiency in care highlights the facility's failure to adhere to its own policies and care plans, leading to inadequate pressure ulcer prevention for the resident.
Failure to Follow Speech Therapy Recommendations for Resident with Dysphagia
Penalty
Summary
The facility failed to adhere to speech therapy recommendations for a resident with cognitive impairment and a secondary diagnosis of dysphagia. The resident's care plan and Kardex did not reflect the hospital discharge orders, which specified a regular diet with thin liquids and no straws. Despite these orders, the resident was observed using straws during meals, as facilitated by a nursing assistant who was under the impression that straw use was permissible. This misunderstanding was further compounded by a licensed practical nurse who was unaware of the no-straw order, assuming it was outdated. The resident had not been re-evaluated by speech therapy since their discharge from the hospital, despite improvements that led to their graduation from hospice care. The registered nurse confirmed that the no-straw order was still in place from the initial hospital discharge. The speech therapist acknowledged the lack of a recent evaluation and suggested that a re-evaluation or a risk-benefit assessment could be conducted to address the use of straws. The Director of Nursing expected staff to follow dietary instructions and seek clarification if there were any discrepancies, as outlined in the facility's policy on diet orders.
Failure to Assess Resident for Bed Rail Safety
Penalty
Summary
The facility failed to properly assess a resident, identified as R12, for the use of bed rails, which is a necessary step before their installation. The report highlights that the facility did not conduct a safety assessment for R12, despite the presence of bilateral side rails on the resident's bed. Interviews with various staff members, including registered nurses and the director of nursing, revealed inconsistencies in understanding the requirements for bed rail installation. While some staff members acknowledged the need for a doctor's order, consent, and a safety assessment, there was confusion about who was responsible for completing the assessment. The facility's policy on bed rails, dated September 8, 2023, mandates that bed rail usage should only occur when supported by a resident assessment and data collection documentation. This policy also requires that the total bed environment be inspected for entrapment risks and that informed consent be obtained. However, the report indicates that these procedures were not followed for R12, as confirmed by the nurse manager and the director of nursing, who both verified the absence of a safety assessment for the resident.
Inappropriate Indication for Antidepressant Use
Penalty
Summary
The consulting pharmacist (CP) failed to address an appropriate indication for the antidepressant bupropion prescribed to a resident reviewed for psychotropic medications. The resident, who had intact cognition, coronary artery disease, hypertension, and had undergone coronary artery bypass grafting (CABG), was taking bupropion 150 mg twice daily. However, the resident's medical records did not indicate a diagnosis of depression, and the bupropion was prescribed for status post CABG, which is not a correct indication for this medication. The pharmacist's medication review did not include any recommendations or concerns regarding the use of bupropion for this resident. During interviews, the CP acknowledged that bupropion is an antidepressant and that CABG is not a correct indication for its use. The Director of Nursing (DON) stated that the pharmacist should have identified the incorrect indication during the initial review. The facility's policy on psychotropic medications emphasizes that residents should be free from unnecessary drugs, defined as those used without adequate indications. Despite this policy, the pharmacist's review failed to address the inappropriate use of bupropion, leading to a deficiency in the resident's drug regimen review process.
Deficiencies in Monitoring and Care Planning for Psychotropic Medications
Penalty
Summary
The facility failed to ensure proper monitoring and implementation of non-pharmacological interventions for residents prescribed psychotropic medications. For one resident, identified as R110, the care plan did not include any non-pharmacological interventions despite the resident being on antipsychotic medication for bipolar disorder and psychosis. The care plan only included monitoring for adverse side effects and consulting with healthcare providers for potential dosage reduction. Interviews with the nurse manager and the director of nursing confirmed the absence of individualized non-pharmacological interventions in the care plan. Another resident, identified as R50, was not monitored for side effects of the psychotropic medications duloxetine and aripiprazole, which were prescribed for depression and dementia. The care plan for R50 lacked documentation of depression and did not include any monitoring for side effects of the medications. The pharmacist's medication review and consultant reviews also failed to address the need for monitoring side effects. Interviews with the consulting pharmacist, registered nurse, and director of nursing confirmed the lack of monitoring and care planning for R50's psychotropic medication use. The facility's policy on psychotropic medications emphasized the need for monitoring and documentation of mood and behavior, as well as the implementation of non-pharmacological interventions before medication use. However, the facility did not adhere to these guidelines, resulting in deficiencies in the care plans and monitoring of residents R110 and R50. The lack of proper documentation and monitoring for side effects and non-pharmacological interventions contributed to the facility's failure to comply with its own policy and regulatory requirements.
Failure to Administer Pain Medication Timely
Penalty
Summary
The facility failed to provide timely pharmacy services for a resident who required oxycodone for pain management. The resident, who was admitted with multiple diagnoses including falls, dementia, and a right foot fracture, had a pain score of eight out of ten on the morning of 4/22/24. A certified nurse practitioner ordered oxycodone to be administered every four hours as needed. However, the resident did not receive the medication until the following day at 4:00 p.m., despite the medication being available in the facility's medication dispensing kit. Interviews with facility staff and the pharmacy account manager revealed that the order for oxycodone was sent to the pharmacy and processed on 4/22/24. The medication was dispatched from the pharmacy late that night, but due to an electronic failure, there was no delivery slip. The facility had the capability to dispense the medication from their kit by obtaining a passcode from the pharmacy, which operates 24/7, but this was not done. The director of nursing confirmed that the staff should have used the dispensing kit to provide the medication while waiting for the delivery.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,024 citations issued within 25 miles in the last 12 months — including the 33 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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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) |
|---|---|---|---|---|
| Harmony Gardens | 2.4 mi | ★★★★★ | 7 | 0 |
| Maplewood Rehabilitation Center | 2.9 mi | ★★★★★ | 26 | 0 |
| Capitol View Transitional Care Center | 3.2 mi | ★★★★★ | 1 | 0 |
| The Villas At Roseville | 3.3 mi | ★★★★★ | 8 | 0 |
| The Estates At Roseville Llc | 3.5 mi | ★★★★★ | 2 | 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.