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 Shirley Chapman Sholom Home East during CMS and state inspections, most recent first.
A resident returned from the hospital with a new catheter and required enhanced barrier precautions (EBP), but the facility failed to update the care plan to reflect these changes. Staff did not wear gowns during high-contact care, and there was no EBP sign outside the resident's room. Interviews confirmed that the interdisciplinary team missed implementing EBP, and the care plan was not revised, contrary to facility policy.
A facility failed to implement enhanced barrier precautions (EBP) for a resident with a catheter, as observed during a survey. The resident returned from the hospital with a catheter, but the care plan did not identify the need for EBP, and there was no signage indicating EBP requirements. Nursing assistants entered the resident's room without gowns and did not follow proper infection control measures when emptying the catheter bag. Staff interviews revealed a lack of awareness and implementation of EBP, contrary to facility policies.
The facility failed to properly store, label, and date food items, and did not maintain required wash temperatures for dishwashers. Observations revealed unlabeled and undated food in freezers and coolers, and dishwashers in the [NAME] and Macalester units did not meet minimum wash temperatures. Staff interviews indicated inconsistent practices in food labeling and temperature monitoring, with the Culinary Services Manager acknowledging the importance of these measures for food safety.
A LTC facility failed to implement appropriate infection control measures, including isolating a resident without symptoms or positive COVID-19 tests, improper hand hygiene practices by staff, and inadequate catheter care. Additionally, clean linen was stored uncovered, risking contamination. These deficiencies were observed by surveyors and confirmed by facility staff.
A resident was found with Tums at their bedside without a self-administration assessment or provider order, despite requiring assistance for daily activities. Staff interviews confirmed the lack of authorization and assessment, indicating a failure to adhere to the facility's policy on medication self-administration.
A resident with heart failure and other conditions experienced a significant weight gain, but the facility failed to notify the provider. Despite the resident's care plan requiring monitoring for weight changes and potential fluid retention, there were no orders for weight monitoring or parameters for provider notification. Interviews revealed an expectation for such monitoring, but it was not documented or executed, leading to a deficiency in care.
The facility failed to provide adequate grooming care for two residents, resulting in unmet needs for shaving and nail care. One resident, with moderate cognitive impairment, was not shaved despite expressing a desire for it, and the care plan lacked specific instructions. Another resident, also cognitively impaired, had unshaven facial hair and overgrown nails, with family concerns about inconsistent care. Facility policies on grooming were not followed, leading to these deficiencies.
A resident with severe glaucoma did not receive necessary eyeglasses due to scheduling errors and miscommunication among facility staff. Despite having a prescription since April, the resident experienced multiple canceled or incorrectly scheduled appointments, leading to frustration and lack of access to vision services. Interviews revealed a breakdown in communication and coordination, with staff unaware of the resident's needs and the facility's policy on appointments not being effectively followed.
A resident with multiple health conditions, including diabetes and end-stage renal disease, did not receive breakfast before dialysis and had inconsistent food intake documentation. The facility lacked specific instructions for providing meals before dialysis, and staff interviews confirmed the absence of a setup for breakfast. The director of nursing expected meal intakes to be documented every shift, but no policy was provided for preparing meals prior to dialysis.
Failure to Update Care Plan for Catheter and EBP
Penalty
Summary
The facility failed to review and revise the care plan for a resident who returned from the hospital with a new catheter and required enhanced barrier precautions (EBP). The resident, who had a diagnosis of neurogenic bladder and was at risk for skin breakdown and urinary tract infection, returned to the facility with a Foley catheter following hospitalization for septic shock due to bacteremia caused by an infected kidney stone. Despite these changes, the resident's care plan was not updated to include the catheter or EBP, leaving staff without proper guidance on managing the resident's catheter care. Observations revealed that nursing assistants did not wear gowns while providing high-contact care to the resident, and there was no EBP sign posted outside the resident's room. Interviews with staff, including a nursing assistant, an LPN, and the director of nursing, confirmed that the interdisciplinary team missed implementing EBP upon the resident's return from the hospital, and the care plan had not been revised. The facility's policy required care plans to be updated as care changes occurred, but this was not followed, resulting in a deficiency in the resident's care management.
Failure to Implement Enhanced Barrier Precautions for Resident with Catheter
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with an indwelling catheter, as observed during a survey. The resident, who had a foley catheter due to urinary retention from a neurogenic bladder, returned from the hospital with a catheter after being treated for septic shock caused by an infected kidney stone. Despite the resident's condition, the care plan did not identify the need for EBP, and there was no signage indicating the requirement for EBP outside the resident's room. During an observation, nursing assistants entered the resident's room without wearing gowns, which are part of the EBP for high-contact care activities. They assisted the resident with incontinent care and emptied the catheter bag without following proper infection control measures. The nursing assistant used an incontinent wipe instead of an alcohol wipe to clean the catheter tubing and placed the urine canister on the carpeted floor without a barrier, contrary to the facility's policy. Interviews with staff, including nursing assistants, a registered nurse, the infection preventionist, and the director of nursing, revealed a lack of awareness and implementation of EBP for the resident. Staff members confirmed that EBP should have been in place due to the resident's catheter, but it was missed upon the resident's return from the hospital. The facility's policies on urinary catheter care and transmission-based precautions were not followed, leading to the deficiency.
Food Storage and Dishwasher Temperature Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, labeling, and dating of food items, as well as maintaining the required wash temperatures for dishwashers. During an observation, it was noted that a large walk-in freezer contained a blue bag of frozen meat without a label or date, and a foil tin pan labeled 11/25 with knishes. Another freezer had items such as butterscotch bars and dough for knishes that were not properly labeled or dated. The Culinary Services Manager (CSM) acknowledged these issues, stating that the box for the turkey breasts might have been destroyed and that the dough should have had a date label. Additionally, the meat cooler contained items labeled with dates that reflected when they were pulled from the freezer, not when they should be used by. The facility's dishwashers in the [NAME] and Macalester units did not meet the minimum wash temperature requirements. The Dish Washer Temperature Log did not specify which dishwasher the temperatures reflected, and June 2024 logs were not provided. Observations showed that the Electrolux dish machine's wash temperature started at 153 degrees but dropped to 147 degrees, while the rinse temperature was 189 degrees. The [NAME] dish washer had a wash temperature of 146 to 148 degrees and a rinse temperature of 188 degrees. The CSM stated that the wash temperature was important, but the final rinse at 180 degrees was the final sanitation step. Interviews with staff revealed that there was confusion and inconsistency in labeling and monitoring food items and dishwashing temperatures. Dietary aides and cooks had varying practices for labeling and rotating food, and there was a lack of clarity on the proper procedures for checking and recording dishwasher temperatures. The CSM acknowledged the importance of proper labeling and temperature monitoring to ensure food safety and prevent illness, but the facility's practices did not align with these standards.
Infection Control and Hygiene Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement the least restrictive infection control measures for a resident (R21) who was exposed to COVID-19. Despite multiple negative test results and no symptoms, R21 was kept in isolation, which was not in accordance with CDC guidelines. The resident had moderately impaired cognition and enjoyed participating in group activities, but was restricted to her room, affecting her mental well-being. The facility's infection preventionist and director of nursing were unable to justify the continued isolation, and there was no documentation supporting the decision to isolate R21. In another instance, the facility failed to ensure proper hand hygiene practices were followed for a resident (R104) under contact precautions. A nursing assistant exited and re-entered the resident's room without performing hand hygiene, even after handling items outside the room. This lapse in protocol was acknowledged by the nursing assistant, who admitted to forgetting the procedure, and was confirmed by a licensed practical nurse who emphasized the importance of hand hygiene to prevent the spread of infection. Additionally, the facility did not adhere to standards of practice for catheter care for a resident (R408). A nursing assistant was observed placing a urinal on the floor without a barrier while draining a catheter bag, which is against infection control practices. The director of nursing confirmed that a barrier should be used to prevent contamination. Furthermore, clean linen was improperly stored on uncovered carts, accessible to residents and visitors, increasing the risk of contamination. The facility's policy required linen to be transported in covered carts, which was not followed, as observed by surveyors.
Failure to Complete Self-Administration Assessment for Resident
Penalty
Summary
The facility failed to ensure a self-administration of medications (SAM) assessment was completed for a resident, identified as R101, who was observed with medications at their bedside. R101, who was cognitively intact but required substantial assistance for daily activities, was found with a bottle of Tums on their nightstand. The bottle was mostly empty, lacked a resident label, and was not included in R101's physician's orders. R101 admitted to taking the Tums after consuming too much candy, despite a SAM assessment indicating they did not want to self-administer medications. Interviews with facility staff, including a nursing assistant and registered nurses, revealed that R101 did not have a provider order or a completed SAM assessment authorizing them to self-administer medications. The staff acknowledged that medications should not be left in a resident's room without proper authorization and assessment. The director of nursing confirmed that an observation assessment and provider order are necessary to ensure residents can safely self-administer medications, highlighting a lapse in the facility's adherence to its policy on self-administration of medications.
Failure to Notify Provider of Significant Weight Gain
Penalty
Summary
The facility failed to notify a provider about a significant weight gain for a resident with a history of heart failure, coronary artery disease, and chronic kidney disease. The resident, who was on a cardiac diet and receiving a diuretic medication, experienced a weight gain of 8.8 pounds in one day and 8.8 pounds over seven days. Despite the resident's medical history and the potential for fluid retention, there were no orders for weight monitoring or parameters to guide staff on when to notify the provider. The resident's care plan included monitoring for signs of cardiac decompensation and adverse reactions to diuretics, such as weight gain and edema. However, the facility's documentation lacked any update to the provider regarding the resident's weight gain. Interviews with nursing staff and the director of nursing revealed that there was an expectation for weight monitoring and provider notification, but these actions were not documented or carried out. The facility's policy required notification of significant changes in a resident's condition, but this was not adhered to in this case. The resident's medical provider confirmed that an order for weight parameters should have been expected, especially given the resident's discharge from the hospital with heart failure. The provider expressed concern about the rapid weight gain, suspecting fluid retention rather than increased caloric intake. The facility's failure to notify the provider of the resident's weight gain was a significant oversight, as it could have led to timely medical intervention.
Failure to Provide Adequate Grooming Care
Penalty
Summary
The facility failed to provide adequate grooming care for two residents, specifically in the areas of shaving and nail care. One resident, who had moderate cognitive impairment and was dependent on staff for personal hygiene, was observed to have a mustache despite expressing a desire to be shaved. The resident's care plan did not include instructions for shaving, and staff interviews revealed a lack of clarity regarding responsibilities for shaving diabetic residents. Observations confirmed that the resident was not shaved on multiple occasions, and the care plan lacked specific interventions for shaving. Another resident, who was cognitively impaired and dependent on staff for personal hygiene, was also not provided with adequate grooming care. The resident's family expressed concerns about the lack of attention to facial hair and nail care, which were not consistently addressed by the facility. Observations showed that the resident had unshaven facial hair and overgrown, jagged fingernails. The care plan did not include instructions for shaving or nail care, and staff interviews indicated that these tasks were not consistently performed. The facility's policies on shaving and nail care were not followed, leading to deficiencies in the care provided to these residents. The policies stated that female residents should be shaved as needed and that nail care should be provided weekly on bath days. However, the facility failed to ensure these grooming tasks were completed, resulting in unmet care needs for the residents involved.
Failure to Provide Vision Services
Penalty
Summary
The facility failed to provide assistance to ensure eyeglasses were available for a resident, identified as R20, who was reviewed for vision needs. R20 had a history of severe glaucoma in both eyes, requiring corrective lenses to maintain adequate vision. Despite having a prescription for glasses since April, R20 did not receive the necessary eyeglasses due to a series of appointment scheduling errors and miscommunications between the facility staff and the eye care provider. R20's care plan included interventions such as arranging eye exams and assisting with glasses, but these were not effectively implemented. The resident's nursing progress notes indicated multiple instances where appointments were either canceled or incorrectly scheduled, leading to R20 being turned away from the eye care center. Additionally, there was a lack of follow-up on the part of the health unit coordinators and nursing staff to ensure that R20 received the prescribed glasses. Interviews with facility staff revealed a breakdown in communication and coordination regarding R20's eye care appointments. The health unit coordinator and registered nurse were unaware of the status of R20's glasses, and there was confusion about whether an appointment was needed for fitting. The director of nursing confirmed that medical records were responsible for setting up appointments and transportation, but the facility's policy on resident appointments was not effectively followed, resulting in R20's continued lack of access to necessary vision services.
Failure to Provide Breakfast Before Dialysis and Monitor Food Intake
Penalty
Summary
The facility failed to provide breakfast to a resident before dialysis and did not adequately monitor the resident's food intake. The resident, who had multiple health conditions including diabetes, end-stage renal disease, and was on dialysis, reported not receiving breakfast on dialysis days. The resident stated that when she asked for breakfast, she was told the kitchen was closed, and she could only get coffee or a cookie. The care plans and care sheets for the resident lacked specific instructions for providing a meal before dialysis, and there was no documentation of breakfast intake on several occasions. Interviews with staff revealed that the resident was picked up for dialysis early in the morning, before the kitchen opened, and returned around 11:00 a.m. The registered dietician and nursing staff acknowledged the lack of documentation for meal intakes and the absence of a setup for providing breakfast before dialysis. The registered dietician noted that high-risk residents, such as those on dialysis, should have their food intakes monitored and documented, but this was not consistently done for the resident. The director of nursing expected meal intakes to be documented every shift and stated that food should always be available for residents. However, the facility did not provide a policy outlining the process for preparing meals for residents prior to dialysis or documenting meal intakes. This lack of documentation and preparation contributed to the deficiency in ensuring the resident received adequate nutrition before dialysis.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Saint Paul
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hayes Residence | 1.6 mi | ★★★★★ | 0 | 0 |
| Highland Chateau Health And Rehabilitation Center | 1.7 mi | — | 55 | 2 |
| Carondelet Village Care Center | 2 mi | ★★★★★ | 6 | 0 |
| Little Sisters Of The Poor | 2.2 mi | ★★★★★ | 5 | 0 |
| The Emeralds At St Paul Llc | 2.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.