Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 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.
Unlabeled open insulin and liquid Ativan were found during observation. An RN prepared to give Lispro insulin to a resident, but the insulin pen had no open date or initials. In the medication room refrigerator, two open bottles each of liquid Ativan for two hospice residents had blank open-date labels, and staff confirmed the bottles should have been dated when opened and the older bottle discarded when a newer one was opened. The DON stated multiple opened bottles should not have been present.
Improper Sanitization of Food Thermometer: A dietary aide used a napkin to wipe a food thermometer between checking ready-to-serve foods on a steam table, and another dietary aide described the same practice. The CSD stated the expected process was to sanitize the thermometer between food items using the facility’s sanitizer and then dry it before the next use, while the DON stated proper sanitization was expected to prevent cross contamination and foodborne illness.
Unassessed Bedside Eye Drops Kept in Resident Room: A cognitively intact resident with multiple chronic conditions had two unlabeled eye drop bottles, Systane Complete and ketotifen fumarate, observed unsecured on his bedside table. The resident’s SAM assessment indicated he did not want to self-administer medications, his care plan did not address bedside storage or self-administration of the eye drops, and the medical record lacked provider orders or authorization for bedside keeping. Staff stated the drops may have come from home and were being given at the resident’s request, while the DON stated a completed assessment and provider order were required before medications could be kept in the room.
PRN psychotropic medication was ordered for a resident with severe cognitive impairment, hospice services, and multiple diagnoses, including Alzheimer's disease, depression, and psychotic disorder, but the record lacked the required provider rationale for extending the PRN lorazepam order beyond the 14-day limit. The MAR showed no doses were administered during the reviewed period, and both the DCS and DON stated PRN psychotropic orders are initially limited to 14 days unless the prescriber documents justification for a longer duration.
Failure to Notify Ombudsman of Resident Discharges: The facility did not send required OOLTC discharge notices for two cognitively intact residents. One resident was transferred to the hospital after a change in condition, and another left AMA, but neither discharge was documented on the facility’s ombudsman notification records. The DCS and administrator confirmed the missing notifications, and the facility policy required forwarding all discharge notices to the OOLTC and other required state agencies.
A resident with edema and multiple cardiac and metabolic diagnoses was repeatedly observed without ordered bilateral leg wraps, despite the TAR and staff acknowledgment that the wraps should be applied first thing in the morning. In a separate issue, a resident receiving hospice services had incomplete hospice documentation in the chart, only one hospice RN note for the month, and facility staff could not identify the hospice schedule or clearly describe the hospice services being provided. The DON stated the facility expected hospice information and documentation to support coordinated care, but staff and hospice records were not consistently available to the nursing team.
Failure to Implement Fall Interventions: A resident with stroke, dementia, impaired cognition, and a history of falls was identified as a fall risk with care plan interventions including proper footwear and walker use. Observations showed the resident barefoot or wearing plain socks without grips while getting up, walking in the hallway, and lying in bed, and staff interviews confirmed grip socks should have been in place and that no refusal was documented.
Failure to Document Foley Indication and Maintain Catheter Care: A resident admitted with urinary retention, dementia, and severe cognitive impairment remained on a foley after the planned trial void was delayed without documented clinical justification. Staff observed the catheter bag not hanging below the waist and tubing looped with urine sitting in it, while interviews confirmed the bag should have been to gravity and that there was no documentation of family involvement or education about the risks and benefits of keeping the catheter in place.
A resident with severe cognitive impairment and total care needs was on EBP because of a pressure wound on the heel, and the care plan required a gown and gloves for high-contact care. During observation, a nursing assistant provided personal care, including repositioning, perineal care, brief and clothing changes, without wearing the required gown. The nursing assistant later said she thought the resident was not on EBP, while the LPN and DON stated staff were expected to follow the care plan and use PPE as required.
Survey results binder near the elevators did not include the facility's POC for the most recent survey or the prior 3 years, and there was no indication that the POCs could be requested from facility staff. The administrator confirmed the missing POCs after reviewing the binder, and the facility did not provide the policy on posting survey results.
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.
Unlabeled Open Medications
Penalty
Summary
The facility failed to ensure multi-dose medications were labeled when opened and discarded according to professional standards in 1 of 2 medication rooms reviewed and 1 of 5 medication carts reviewed. During an observation on 7/20/26, an RN was preparing to administer Lispro insulin to R92, who had been admitted for short-term rehabilitation on 7/16/26. When the insulin pen was removed, the open date and initials label was blank. The RN stated insulin pens were supposed to be dated with the open date, but on the transitional care unit it sometimes gets missed because residents are not there very long. In the third-floor medication room refrigerator on 7/22/26, two open bottles of liquid Ativan for R42 and two open bottles of liquid Ativan for R25 were observed. The bottles had open date and initial labels, but all were blank, and the bottles were not full. R42's quarterly MDS indicated severe cognitive impairment and hospice services, and R25's significant change MDS indicated severe cognitive impairment and hospice services. RN-F verified the bottles and missing opening dates and stated they should be dated when opened and the older one should have been discarded when the newer one was opened. LPN-A stated medications should be labeled when opened because they are good for only so long. RN-B stated insulin pens were expected to be dated when opened, and the DON stated multiple bottles of opened medications should not be happening. The facility policy directed staff to follow manufacturer or supplier guidelines for expiration dates and to record the date opened on the primary medication container.
Improper Sanitization of Food Thermometer
Penalty
Summary
The facility failed to ensure a proper sanitization technique was used when obtaining food temperatures from ready-to-serve meals on the steam table. During observation on 7/21/26 at 11:50 a.m. on the fourth floor, a dietary aide placed stainless steel trays of food on the steam table, washed her hands, put on gloves, and used a food thermometer to check temperatures. After checking the soup, she wiped the thermometer with a napkin and then used the same napkin again after checking the steamed vegetables. The dietary aide stated she always used a napkin to clean the thermometer between food items and had never been told otherwise. During later interviews, another dietary aide stated he used a napkin to clean the thermometer between food items and then used a sanitizer solution before putting it away. The CSD stated the expectation was for dietary aides to check food temperatures before food was placed on the steam table, record the temperatures, wipe the thermometer with sanitizing solution, and dry it with a paper towel before checking the next item. The CSD also stated the facility used Ecolab Oasis 146 Multi-Quat Sanitizer and acknowledged that new employees needed further education. The DON stated the expectation was for staff to follow proper sanitization procedures to clean food thermometers to prevent cross contamination and reduce the risk of foodborne illnesses. The facility policy stated the thermometer would be sanitized using a thermometer wipe in between foods of different types to prevent cross contamination.
Unassessed Bedside Eye Drops Kept in Resident Room
Penalty
Summary
The facility failed to ensure self-administration of medications was assessed and determined to be appropriate for one resident who was reviewed for self-administration of medications. The resident’s quarterly MDS indicated he was cognitively intact and required varying levels of assistance with activities of daily living and mobility. His diagnoses included low blood pressure when standing, heart failure, chronic kidney disease, lung disease, and a pacemaker. However, his Self-Administration of Medications assessment indicated he answered no when asked whether he wanted to self-administer medications or treatments. The resident’s care plan did not identify interventions related to bedside storage or self-administration of eye medications, and the medical record lacked provider orders for Systane Complete or ketotifen fumarate eye drops or authorization for the medications to be kept at the bedside. During observation, two bottles of eye drops were found unsecured on the resident’s bedside table without pharmacy prescription labels. The resident stated the eye drops were not facility medications and that staff administered them at his request. Later observations confirmed the eye drops remained at the bedside, and nursing staff verified the medications lacked labels and stated a SAM assessment and provider order were required before medications could be kept in a resident’s room. The DON stated residents needed to be able to safely self-administer medications, have a completed assessment, and have a provider’s order before keeping medications in their room.
PRN Psychotropic Medication Ordered Without Required Rationale
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication was limited to 14 days or extended to a specific date with supporting rationale documented by the medical provider for one resident. The resident had severe cognitive impairment, received hospice services, and had diagnoses including atrial fibrillation, congestive heart failure, renal failure, Alzheimer's disease, depression, and psychotic disorder. The resident's medical orders included lorazepam 0.5 mg orally every 6 hours as needed for anxiety with a discontinuation date in 9/2026, and the resident's MAR showed no doses of lorazepam were given between 3/2026 and 7/2026. The resident's medical record lacked supporting rationale for the lorazepam PRN order. During interview, the corporate DCS stated a PRN psychotropic medication could not be ordered for more than 14 days at the time and required a face-to-face visit and rationale from the doctor to extend it beyond 14 days. The DON stated the initial PRN psychotropic order could not be for longer than 14 days, and after that it needed review, with the doctor able to rewrite it for another 14 days or schedule the medication if necessary. The facility policy stated residents should be free from chemical restraints and unnecessary medications, and that PRN psychotropic drugs are limited to 14 days unless the prescriber documents rationale and duration for extension.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to ensure that discharge notices were sent to the Office of the State Long-Term Care Ombudsman for 2 residents reviewed for discharge. One resident was cognitively intact and had diagnoses including hepatic encephalopathy, chronic liver failure, cirrhosis, systolic congestive heart failure, and chronic kidney disease. That resident had a change in condition, the provider ordered transfer to the hospital for further evaluation, and the resident left the facility with paramedics. However, the facility’s monthly ombudsman notice did not include this facility-initiated hospital transfer, and the Corporate Director of Clinical Services confirmed it should have been listed on the April notification log. The second resident was also cognitively intact and had no hallucinations, delusions, or behaviors. The resident was discharged against medical advice, but the facility had no record of ombudsman notification for that discharge. The Ombudsman stated that no transfer and discharge notices had been received from the facility for approximately two years, with the last notice received in May 2024. The facility’s monthly notice listed 18 hospital transfers for April but did not include the resident’s discharge, and the administrator stated there was no evidence of notification. The facility policy required forwarding a copy of all discharge notices to the OOLTC and required state agencies.
Failure to Follow Leg Wrap Orders and Coordinate Hospice Services
Penalty
Summary
The facility failed to follow provider orders for a resident with edema who had diagnoses including essential hypertension, non-rheumatic aortic stenosis, diabetes type II, prosthetic heart valve replacement, morbid obesity, and metabolic encephalopathy. The resident’s medical orders included applying bilateral lower-extremity leg wraps in the morning and removing them at night, and the treatment record included that order. However, during multiple observations, the resident was seen without the leg wraps on, with the wraps left on a bedside table, and the resident stated staff sometimes got busy and did not wrap her legs. A nurse stated he was running behind and would try to wrap the resident’s legs as soon as possible, and the nurse manager verified the wraps were not on and said she would do it. The director of nursing stated the leg wraps and compression stockings should be applied first thing in the morning. The DON also stated that if the wraps or stockings were not applied, the resident’s edema could worsen, cause fluid overload, worsen cardiac-related symptoms, and possibly have a negative effect on the resident’s wellbeing. A policy regarding edema and following doctor’s orders was requested but not provided. The facility also failed to ensure effective collaboration with hospice services for a resident with severe cognitive impairment, stroke, atrial fibrillation, congestive heart failure, hypertension, Alzheimer’s disease, and hospice services. The resident’s record showed hospice orders, but only one hospice nurse progress note was present for the month reviewed. Staff were unable to identify the hospice schedule or locate a hospice binder in the EMR, and the hard chart lacked a hospice care plan and current hospice certification. Although a hospice schedule existed in the hard chart, nursing staff and nursing assistants stated they did not know what hospice services were being provided or when hospice staff were scheduled to visit, and the hospice program manager stated the hospice nurse needed to copy progress notes into the facility EMR while other team members documented in a hospice communication book kept in the resident’s room.
Failure to Implement Fall Interventions
Penalty
Summary
The facility failed to ensure fall interventions were implemented for a resident at risk for falls. The resident had diagnoses including stroke with aphagia, dementia with mood disturbance, and a history of falling. The comprehensive nursing assessment indicated short- and long-term memory problems, severely impaired cognitive skills for daily decision making, and a history of falling prior to admission. The care plan identified the resident as needing assistance of one staff member with a gait belt and four-wheeled walker for transfers and mobility, and listed fall-risk interventions including keeping the bed at transferring height, keeping the call light in reach, and ensuring the resident wore appropriate footwear. Observations showed the resident barefoot and not using the walker while walking toward the hallway from the bed, with shoes on the floor nearby, and an unidentified NA had to escort the resident back to the room. Later observations showed the resident wearing plain socks without grips and no shoes while in bed or in the hallway. Staff interviews confirmed the resident was a fall risk, had fallen since admission, and should have had grip socks in place. The NA, LPN, RN, and DON all stated appropriate footwear for the resident included grip socks in bed and grip socks or shoes when walking, and the RN and DON stated the grip socks should have been in place. The medical record did not indicate the resident refused grip socks, and the facility policy directed staff to implement interventions according to resident-specific risk factors and care plans.
Failure to Document Foley Indication and Maintain Catheter Care
Penalty
Summary
The facility failed to ensure documentation of the clinical indication for continued foley catheter use was in place and failed to ensure interventions were in place to prevent UTIs for one resident with a catheter. The resident was recently admitted with diagnoses including stroke with aphasia, dementia with mood disturbance, urinary retention, and a urinary device. The resident’s assessment indicated severe cognitive impairment and that the resident was admitted with a foley catheter. Hospital discharge information showed the resident had hematuria and urinary retention, required a urology consultation, and was discharged with a plan for catheter removal and a trial of void at the skilled nursing facility. Provider orders directed catheter removal and a trial void, and also directed that the catheter be kept to gravity drainage with the tubing not looped or kinked and the drainage bag kept below the waist. The care plan identified the resident as having a foley catheter related to neurogenic bladder and being at risk for UTI, with interventions to change the foley when needed and keep the tubing and bag below the bladder and free of kinks. However, nursing documentation showed the trial void was delayed after staff reported the resident was impulsive and self-transferring, and a later provider note stated the resident would need a trial void and continued foley care without documenting the clinical indication for delaying catheter removal. Observations showed the catheter bag was not hanging to gravity and was not below the resident’s waist, and the tubing was looped with urine sitting in the tubing. Staff interviews confirmed they were unsure why the catheter remained in place, acknowledged the bag should be below the waist and to gravity, and stated the tubing should not have loops or kinks. One nurse stated the resident had fidgeted with the catheter and caused bleeding requiring replacement, and another stated the catheter was kept an additional week. The medical record lacked documentation that the family had been involved in the decision to delay discontinuation of the catheter or that risks and benefits of keeping it in place had been discussed.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff followed infection prevention and control practices by using the required PPE during Enhanced Barrier Precautions for one resident. The resident had severe cognitive impairment and was dependent on staff for total body care, bed mobility, and transfers. Diagnoses included chronic heart failure, chronic kidney disease, and nontraumatic intracranial hemorrhage. The resident’s care plan indicated EBP had been initiated because of a pressure wound on the right heel and directed staff to wear a gown and gloves during high-contact care activities such as dressing, hygiene care, and changing briefs. During observation, a nursing assistant provided personal care without wearing the required gown. The nursing assistant wore a mask and gloves but did not don a gown while repositioning the resident, performing perineal care, changing the brief and clothing, and completing additional personal care. During interview, the nursing assistant stated she believed the resident was not on EBP because there was no sign on the door, but later acknowledged there was a sign above the sanitizer dispenser indicating EBP and that a gown and gloves should have been worn. The LPN and DON stated staff were expected to consistently follow each resident’s care plan and don and doff PPE in accordance with EBP requirements. The facility policy stated EBP required a gown and gloves during high-contact resident care activities.
Survey Results Binder Missing Required POCs
Penalty
Summary
The facility failed to ensure that the plan of correction (POC) for the most recent survey was readily accessible and that the POC for the three preceding years was available upon request. During observation and record review, the survey results binder located near the elevators on the first floor contained survey results from the past three years, but the 2024 and 2025 survey results did not include the facility's POC or indicate that these could be requested from facility staff. The administrator stated that she was responsible for maintaining the binder and confirmed that the POCs for all surveys occurring from 2024 to current were missing from the binder. A request for the facility policy regarding posting survey results was made, but it was not provided.
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.
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 1,197 citations issued within 25 miles in the last 12 months — including the 32 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Saint Paul
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hayes Residence | 1.6 mi | ★★★★★ | 0 | 0 |
| Highland Chateau Health And Rehabilitation Center | 1.7 mi | — | 28 | 1 |
| 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 October 2026) and official state health department websites.