Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Presbyterian Homes Of Arden Hills during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of falls was not provided scheduled toileting or adequate supervision as outlined in her care plan. She was left unsupervised in her room, attempted to toilet herself, and was found on the bathroom floor with a head laceration requiring emergency care and hospitalization. Staff interviews and documentation confirmed that the care plan was not followed, leading to the incident.
A resident with multiple chronic conditions experienced a significant decline in a pressure ulcer, but facility staff delayed consulting the physician and transferring the resident to the hospital for debridement. Despite the MD's recommendation for immediate hospital transfer, staff waited for the NP to assess the wound, resulting in a delay of over 24 hours before the resident received necessary care.
Staff did not wear required gowns, only gloves, while assisting a resident with an indwelling catheter and on enhanced barrier precautions during a transfer. Despite facility policy and signage directing the use of both gowns and gloves for high-contact care, staff acknowledged forgetting to wear gowns during the observed event.
The facility failed to properly dispose of and store food in two of four serving kitchens. Observations revealed expired and improperly stored food items, including an opened box of cream of wheat without a use-by date and milk past its best used by date. Uncovered and undated beverages were also found. Staff interviews indicated a lack of adherence to food storage policies, with no clear method for checking expiration dates.
The facility failed to implement proper infection control measures for residents with COVID-19, as staff did not consistently use required PPE or perform hand hygiene. A resident with severe cognitive impairment and two cognitively intact residents were not provided with appropriate TBP, as staff entered their rooms without necessary protective gear. Additionally, a resident requiring personal care did not receive proper hand hygiene practices from staff, who failed to change gloves and wash hands after handling soiled items.
The facility failed to report allegations of neglect and verbal abuse involving two residents. One resident was left unattended, missing breakfast and morning care, while another was verbally threatened by a nursing assistant. Despite witnessing and acknowledging these incidents, the facility did not file the required vulnerable adult reports.
A resident with severe cognitive impairment and limited mobility did not receive proper positioning with a pillow to prevent pressure ulcers, as required by their care plan. Despite clear instructions and signage, staff failed to consistently place a pillow under the resident's left elbow, as observed during multiple instances. Interviews with staff revealed a lack of adherence to the care plan, which was confirmed by the DON.
A resident with chronic respiratory failure did not receive proper oxygen maintenance as per physician's orders. Observations revealed outdated oxygen tubing and improper handling of the nasal cannula, which was placed in the resident's nose after being on the floor. Staff interviews highlighted inconsistencies in following the facility's oxygen equipment maintenance policy.
A resident with a history of trauma and diagnoses of major depressive and anxiety disorder did not receive trauma-informed care at the facility. Despite a preference for female caregivers and a documented history of trauma, the facility failed to assess potential triggers or offer specialized services. Interviews revealed that the resident had not been assessed for triggers, and her trauma history was known to the facility. The facility's policy on trauma-informed care was not followed, as assessments and documentation of offered services were lacking.
A resident with cognitive impairment and delusional disorder did not receive their prescribed Seroquel due to unavailability. Despite multiple refill requests, the medication was not delivered on time, resulting in a missed dose. Facility staff and the pharmacist cited issues with refill timing and delivery processes.
Two residents in an LTC facility experienced medication administration errors, leading to a 7.69% error rate. One resident did not receive their prescribed Seroquel due to unavailability, while another received Synthroid after breakfast, contrary to instructions to take it on an empty stomach. The facility's processes for medication reordering and administration timing contributed to these errors.
Failure to Provide Scheduled Toileting and Supervision Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision and scheduled toileting for a resident with a history of falls and severe cognitive impairment. The resident's care plan required supervision, regular toileting every three hours, and that she be kept in common areas for monitoring. Despite these interventions being documented, staff did not follow the care plan on the day of the incident, resulting in the resident not being toileted between 4:51 a.m. and 9:29 p.m., with a significant gap in care during the evening hours. On the day of the incident, the resident was last toileted at 4:30 p.m. and was observed at the nurse's station and dining room throughout the afternoon and early evening. However, she was allowed to return to her room unsupervised at approximately 8:22 p.m. Staff did not redirect her to the common area or provide the scheduled toileting. Shortly after, staff found her on the bathroom floor with a head laceration, which required emergency medical attention and resulted in hospitalization. The resident was unable to use the call light and had a history of attempting to self-transfer, which increased her risk for falls. Interviews with staff and review of documentation confirmed that the care plan was not followed, specifically regarding scheduled toileting and supervision. Staff acknowledged that the resident should have been toileted and kept within sight, and that failure to do so likely contributed to her attempting to toilet herself, leading to the fall and injury. The facility's own investigation and camera footage corroborated that the resident was not provided the required supervision or assistance as outlined in her care plan.
Delay in Physician Notification and Treatment for Pressure Ulcer
Penalty
Summary
The facility failed to immediately consult with a resident's physician regarding a significant change in the resident's condition, specifically the deterioration of a pressure ulcer. The resident, who had a history of atrial fibrillation, chronic kidney disease stage 3, spinal stenosis, and sarcoidosis, was noted to have a worsening sacral ulcer with redness, odor, and drainage. The medical director (MD) assessed the wound and recommended immediate hospital transfer for debridement. However, facility staff delayed this action, waiting for orders from the nurse practitioner (NP), who wanted to assess the wound personally the following day. This resulted in a delay of more than 24 hours before the resident was sent to the hospital, despite the MD's recommendation for urgent care. Interviews with facility staff revealed that it was protocol to obtain orders from the NP even when the MD had already given a recommendation for hospital transfer. The MD was not informed that the NP disagreed with his recommendation, and the facility administrator expressed a preference for direct hospital or wound clinic admission rather than emergency room transfer. The facility's policy required staff to notify practitioners of significant changes in a resident's condition, but this was not followed in a timely manner, leading to a delay in necessary treatment for the resident's rapidly deteriorating pressure ulcer.
Failure to Use Proper PPE During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow proper personal protective equipment (PPE) protocols for a resident on enhanced barrier precautions (EBPs) who had an indwelling catheter and required extensive assistance with care. The resident's care plan and signage on the door directed staff to wear gowns and gloves during high-contact care activities, including transfers. During an observed transfer, three staff members, including two nursing assistants and a registered nurse, only wore gloves and did not don gowns while assisting the resident with a transfer using a mechanical lift. After the transfer, they removed their gloves, sanitized their hands, and exited the room. Interviews with the involved staff confirmed that they were aware the resident was on EBPs and acknowledged that gowns should have been worn during the transfer, but they forgot to do so. The infection preventionist and the director of nursing both stated that staff are expected to wear gowns and gloves for high-contact care with residents on EBPs, including transfers. The facility's policy also required targeted use of gowns and gloves for residents with indwelling medical devices during high-contact care activities.
Improper Food Storage and Disposal in Serving Kitchens
Penalty
Summary
The facility failed to ensure proper disposal and storage of food items in two of the four serving kitchens reviewed. During an observation of the 3rd floor serving kitchen, it was found that an opened box of instant cream of wheat had no use-by date, and an unopened box had a best if used by date that was not adhered to. The server responsible for the kitchen was unsure about the usability of the opened box and acknowledged that both boxes should have been removed. Similarly, in the 2nd floor serving kitchen, two containers of skim milk were found, one of which was past its best used by date by six days. The server in this kitchen admitted that the milk should have been checked and disposed of, but due to busyness, this was overlooked. Additionally, in the 4 north serving kitchen, uncovered and undated glasses of milk and apple juice were found in the refrigerator, prepared for the evening shift. The server was unaware of the requirement to cover the beverages and began covering them upon realization. Interviews with the lead server and the Assistant Dietary Director revealed that there was an expectation for staff to check food items daily and ensure proper labeling and storage. However, the facility's policy on safe food storage did not specify a method for checking expiration dates, contributing to the oversight.
Failure to Implement Proper Infection Control Measures
Penalty
Summary
The facility failed to ensure appropriate transmission-based precautions (TBP) for three residents who tested positive for COVID-19. Resident R69, with severe cognitive impairment and dementia, was observed to be in quarantine with a sign indicating the need for droplet precautions, including gown, gloves, eye protection, and an N-95 respirator. However, a nursing assistant (NA-A) entered R69's room without a gown or eye protection, only wearing personal eyeglasses, and assisted with breakfast. NA-A acknowledged not wearing a gown, believing it was only necessary for close contact care. Similarly, residents R108 and R4, both cognitively intact and diagnosed with COVID-19, were observed under TBP. NA-B entered their rooms without donning an N-95 respirator or eye protection, leaving the doors open while delivering meals. NA-B admitted to not wearing the required protective equipment, thinking it was only needed for close contact care. The infection preventionist and the Director of Nursing (DON) confirmed that staff were expected to wear all required personal protective equipment (PPE) when entering rooms of residents with COVID-19. Additionally, the facility failed to ensure proper hand hygiene during personal care for resident R46, who was incontinent and required assistance. NA-B did not perform hand hygiene or change gloves after removing R46's soiled brief and before placing a clean one. NA-B acknowledged the oversight, stating they should have performed hand hygiene and exchanged gloves. The facility's policies on COVID-19 precautions and hand hygiene were not followed, contributing to the deficiencies observed.
Failure to Report Allegations of Neglect and Verbal Abuse
Penalty
Summary
The facility failed to report allegations of potential neglect and verbal abuse to the state agency for two residents. One resident, who had cognitive and functional deficits, was left unattended in bed for several hours, missing breakfast and morning care. This resident required extensive assistance for all activities of daily living and was at risk for developing pressure ulcers. The incident was captured on video, but no written follow-up was completed, and the resident's skin was not assessed for potential pressure injuries. Another resident, who had dementia and required assistance with eating, was verbally threatened by a nursing assistant. The nursing assistant told the resident to stop crying or they would stop feeding them. This incident was witnessed by a registered nurse who intervened and reported the encounter to the nursing assistant's supervisor. However, there was no indication that a vulnerable adult report was filed for this incident. Interviews with facility staff revealed that the incidents were not reported to the state agency as required. The administrator acknowledged that a vulnerable adult report should have been completed for both residents. The facility's policy on abuse prevention outlines the need for immediate reporting and investigation of suspected abuse, but these steps were not followed in these cases.
Failure to Provide Proper Positioning for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R30, received appropriate positioning with a pillow to prevent pressure ulcers and aid in comfort associated with contractures. R30 had severely impaired cognitive skills, impairments in range of motion, and was dependent on staff for all activities of daily living. The care plan indicated that R30 was at risk for impaired skin integrity and required a pillow under the left elbow while in bed and in the chair. However, during multiple observations, R30 was found without the necessary pillow under the left elbow, contrary to the care plan instructions. Interviews with staff, including nursing assistants and registered nurses, revealed inconsistencies in the application of the care plan. Staff members were either unaware or did not adhere to the requirement of placing a pillow under R30's left elbow, despite signage in the room and care plan directives. The director of nursing confirmed that staff were not following the plan of care, emphasizing the importance of the pillow for preventing skin issues and aiding with contractures. The facility's policy required staff to review care plans and complete personal care as indicated, which was not followed in this instance.
Improper Maintenance of Supplemental Oxygen
Penalty
Summary
The facility failed to ensure proper maintenance of supplemental oxygen for a resident with chronic respiratory failure and hypoxia. The resident required extensive assistance with daily activities and had a physician's order to maintain oxygen saturation levels above 88% using 1 to 4 liters of oxygen via nasal cannula, with tubing changes every week. However, during an observation, it was noted that the resident's oxygen tubing and bubbler were dated over a week old, and the nasal cannula was found on the floor before being placed back in the resident's nose by a nursing assistant. Interviews with staff revealed inconsistencies in the understanding and implementation of oxygen equipment maintenance protocols. A registered nurse confirmed that the oxygen tubing should have been changed weekly and should not have been used after falling on the floor. The Director of Nursing acknowledged the lack of a backup plan for changing oxygen tubing when the designated staff member was unavailable. The facility's policy, which was not followed, stated that oxygen tubing should not touch the floor and should be changed weekly.
Failure to Provide Trauma-Informed Care for Resident with History of Trauma
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident with a history of trauma. The resident, who had intact cognition and diagnoses of major depressive and anxiety disorder, was noted to socially isolate herself and required assistance with toileting and mobility. Despite having a documented history of trauma and a preference for female caregivers, the facility did not assess potential triggers to prevent re-traumatization or offer specialized services. The resident's care plan and medical records lacked documentation of such assessments or services being offered or refused. Interviews revealed that the resident had not been assessed for triggers, and her son had informed the facility of her trauma history upon admission. The household coordinator acknowledged that the LTC Psychosocial assessment should have included questions about past trauma and triggers, and that services like ACP should have been offered and documented. The director of nursing confirmed that household coordinators were responsible for completing assessments for trauma-informed care and documenting any offered services. The facility's policy emphasized the importance of assessing residents with a history of trauma to provide appropriate treatment and minimize re-traumatization, which was not adhered to in this case.
Failure to Administer Prescribed Medication Due to Refill Delays
Penalty
Summary
The facility failed to provide medication as ordered for a resident with cognitive impairment and diagnoses of dementia and delusional disorder. The resident was prescribed Seroquel, an antipsychotic medication, to be taken daily at bedtime. However, the medication was not administered on a specific date because it was unavailable. The medication administration record confirmed the absence of the dose, and a nursing progress note indicated that follow-up with the pharmacy was needed. Despite multiple refill requests submitted by the facility, the medication was not delivered in time, resulting in a missed dose. Interviews with facility staff revealed that the medication was re-ordered when the supply was low, but the delivery was delayed. The trained medication assistant noted that the last dose was given the previous day, and the pharmacy had been contacted for a refill. The Director of Nursing acknowledged the issue and mentioned ongoing efforts to improve the medication delivery process. The pharmacist explained that the initial refill request was too early due to insurance restrictions, and subsequent requests were made closer to the depletion date. Despite these efforts, the medication was not available in the emergency kit, leading to the missed administration.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to prevent medication errors for two residents, resulting in a medication error rate of 7.69%. One resident, who had cognitive impairment and diagnoses of dementia and delusional disorder, did not receive their prescribed Seroquel on a specific date because the medication was not available. The trained medication assistant (TMA) responsible for administering the medication stated that the Seroquel had been reordered the previous day but had not yet arrived. The facility's process involved sending a fax to the pharmacy for refills, with the latest delivery expected between 8:00 and 9:00 p.m. However, if the medication was not on that delivery, it would arrive the following morning. The registered nurse (RN) mentioned that medications should be reordered when there was about a week's worth left, but Seroquel was not included in the emergency kit, leading to the missed dose. Another resident, who was cognitively intact with diagnoses of Parkinson's disease and hypothyroidism, received their Synthroid medication after breakfast, contrary to the pharmacy's instructions to administer it on an empty stomach. The TMA acknowledged that the medication was given after breakfast and stated that while they tried to follow the directions, it was not always administered before breakfast. The medication was scheduled as an 8:00 a.m. dose, which allowed for a larger window of administration. The Director of Nursing (DON) expected staff to follow the medication instructions listed from the pharmacy, and the consultant pharmacist confirmed that Synthroid is better absorbed on an empty stomach. The facility's policy directed that medications ordered to be given on an empty stomach should be administered at least 30 minutes prior to a meal.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,031 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Arden Hills
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Langton Shores | 1.5 mi | ★★★★★ | 1 | 0 |
| St Anthony Health & Rehabilitation | 1.6 mi | ★★★★★ | 0 | 0 |
| The Villas At New Brighton | 1.7 mi | ★★★★★ | 17 | 1 |
| New Brighton Care Center | 1.8 mi | ★★★★★ | 12 | 0 |
| The Estates At Roseville Llc | 2.2 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Presbyterian Homes Of Arden Hills.
100% money-back within 48 hours.
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.