Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sholom Home West during CMS and state inspections, most recent first.
Failure to Notify Ombudsman of Resident Transfers and Discharge: The facility did not notify the OMB-LTC of hospital transfers for two residents, including one with CKD and another with CHF and RA, and did not list a third resident who eloped, was found wandering, and was then discharged with family after the daughter requested to take the resident home. The DON verified the missed notifications, and the facility policy required faxing transfer/discharge notice to the ombudsman.
Incomplete discharge record after resident-initiated discharge. A resident with sepsis, pneumonia, and infective endocarditis, who was moderately cognitively impaired and needed assistance with ADLs, eloped from the facility and was later found wandering off-site. After the family returned the resident and the daughter insisted on taking the resident home, discharge orders were obtained, but the EMR lacked a recapitulation of stay, documentation of meds sent, and care instructions. The DON stated the missing documents were expected to be in the paper chart, but staff could not locate them.
Improper disinfection of a blood glucose monitor occurred when an RN used hand sanitizing wipes to clean the device after checking a resident’s blood glucose. The resident had DM, CKD, and Parkinson’s disease, and the RN stated she had been trained to sanitize BGMs after each use. The DON stated staff were expected to use disinfecting wipes, not hand wipes, and the facility policy and QA/QC manual identified EPA-registered disinfectant wipes for cleaning the monitor.
A resident with severe cognitive impairment and a G-tube had an IV pole and tube feeding pump in the room that were observed with dried tan-colored residue on the pole, all five legs, and the floor below. The same residue remained on repeated observations, and an RN and NM stated the pole and pump should be cleaned when spills are seen and during feeding changes for infection control purposes; facility policy called for daily wiping with disinfectant.
A resident in a LTC facility did not have a functioning call light for several weeks, despite being frequently incontinent and requiring assistance with toileting. The resident had to rely on a roommate's call light and had informed maintenance, but no resolution was provided. Staff interviews confirmed the protocol to report malfunctioning call lights, but no maintenance logs were available for the period in question.
The facility failed to ensure grievance forms and procedures were accessible and visible to residents, violating their rights to voice grievances without reprisal. Residents were unaware of how to file grievances, and forms were not available in all areas. Staff confirmed forms were only on the first floor and required residents to request them, with no option for anonymous submission.
The facility failed to conduct timely care conferences for several residents, impacting the review and revision of their care plans. Residents with conditions like Alzheimer's, hemiplegia, and severe cognitive impairment did not have their care conferences documented or conducted as required. Social services staff were responsible for scheduling these meetings but did not consistently do so, and the Director of Nursing was unaware of these lapses.
A deficiency was identified in a LTC facility where residents were not provided with a process to make their own food selections. Residents reported not being given meal choices and were unaware of alternative menus. Staff interviews revealed inconsistencies in the meal selection process, with no menus posted in dining areas. The facility's policy on offering alternate selections was not effectively implemented, leading to residents feeling they had no choice in their meals.
A facility failed to conduct a Level II PASARR for a resident diagnosed with new mental health conditions, including delusional disorders and major depressive disorder. Despite the resident's significant change in mental health status, no updated PASARR screening was completed. Interviews revealed a lack of process for ensuring new screenings after new diagnoses, contrary to the facility's policy.
A resident with moderate cognitive impairment and a preference for activities such as listening to music and going outside was not offered activities in their preferred language, Spanish. The facility lacked documentation of activities being offered or refused, and staff interviews revealed that the resident was not invited to activities due to a language barrier. The facility's policy emphasized meaningful activities, but the resident felt isolated and like a "bird in a cage" due to the lack of Spanish-speaking activities.
A resident with dementia and impaired mobility, at high risk for pressure ulcers, was not repositioned every two hours as required by their care plan. Observations showed the resident remained in the same position for extended periods, contrary to the facility's Skin Integrity Management policy. Staff interviews confirmed the care plan was not consistently followed, leading to a deficiency in pressure ulcer care.
The facility failed to follow CDC guidelines for infection prevention by not ensuring proper PPE disposal and adherence to enhanced barrier precautions. Staff were observed not discarding PPE before leaving isolation rooms and not wearing gowns during high-contact care for a resident with an indwelling device, contrary to facility policy.
The facility failed to ensure that three residents received pneumococcal vaccinations according to CDC guidelines. Despite the facility's policy to offer and provide vaccinations, the medical records for these residents lacked documentation of receiving the PCV20 vaccine based on shared clinical decision-making. The infection preventionist confirmed the findings, and the DON expected adherence to CDC guidelines.
A resident with CHF experienced a significant weight gain of 16 pounds over six days, but the facility staff failed to notify the physician as required by the care plan. Despite the resident's concerns about weight gain and swelling, the provider was only informed after the resident and family raised the issue directly with a nurse practitioner, leading to the resident being sent to the hospital for CHF exacerbation.
Failure to Notify Ombudsman of Resident Transfers and Discharge
Penalty
Summary
The facility failed to ensure the Ombudsman for Long Term Care was notified of resident transfers or discharges for 3 of 5 residents reviewed. One resident with chronic kidney disease and neuralgia/neuritis was sent to the hospital for blood emesis and loss of consciousness, then later readmitted to the facility, but the facility’s February 2026 Monthly Notice to OMB-LTC did not include that hospital transfer. Another resident with moderate cognitive impairment and diagnoses of CHF and rheumatoid arthritis was sent to the hospital for an acute behavioral status change and was admitted with encephalopathy; the family did not wish to hold the bed, yet the February 2026 Monthly Notice to OMB-LTC also lacked this transfer. A third resident with sepsis due to methicillin susceptible Staphylococcus aureus, pneumonia, and acute/subacute infective endocarditis was moderately cognitively impaired and required set up to moderate assistance with all ADLs. The resident eloped from the facility, was later found wandering at Target, and was returned by family, after which the daughter insisted on taking the resident home and discharge orders were received. The facility’s February 2026 listing submitted to OMB-LTC did not include this resident’s name. The DON verified that OMB-LTC was not notified of the first two hospital transfers and stated that notification was expected whenever a resident was transferred to the hospital; the facility policy also stated that transfer/discharge notice was to be faxed to the ombudsman.
Incomplete discharge record after resident-initiated discharge
Penalty
Summary
The facility failed to ensure resident records upon discharge were complete and accurate for one resident who had been admitted with diagnoses including sepsis due to methicillin susceptible staphylococcus aureus, pneumonia, and acute and subacute infective endocarditis. The resident's MDS documented moderate cognitive impairment and the need for set-up to moderate assistance with all ADLs. On 2/08/26, nursing notes documented that the resident eloped from the facility and was later found wandering at Target, after which family returned the resident to the facility. The resident's daughter then insisted on taking the resident home, the provider was contacted, and discharge orders were received. When the resident's electronic medical record was reviewed, it lacked evidence of a recapitulation of stay, documentation of medications sent with the resident, and any care instructions that would have been sent home at discharge. During interviews, the DON stated the missing information would have been in the paper chart and that staff searched the paper record and a pile of documents yet to be scanned but could not find the requested documents. The DON also stated the family had been upset about the elopement and monitoring concerns, wanted to take the resident home, and planned to place the resident on hospice the following morning. The facility policy for resident-initiated discharges required documentation of the resident's notice to leave, a discharge care plan, and documented discussions about discharge planning and post-discharge care.
Improper Disinfection of Blood Glucose Monitor
Penalty
Summary
The facility failed to complete proper disinfection of a blood glucose monitor for one resident who was reviewed for glucose monitoring. The resident’s comprehensive MDS indicated the resident was cognitively intact and had diagnoses including Parkinson’s disease, chronic kidney disease, and diabetes. The physician order report showed an order for blood glucose monitoring twice daily for diabetes, and during observation a RN used an Assure Platinum blood glucose monitor to check the resident’s blood glucose level. After completing the blood glucose check and returning to the medication cart, the RN donned gloves and wiped the entire blood glucose monitor with a wipe from a blue-topped canister of PDI Sani-Hands Instant Hand Sanitizing Wipes, stating she would leave it out to dry. During interview, the RN stated the facility did not use shared blood glucose monitors and that each resident had their own, and she stated she was trained to sanitize the monitors after each use. The DON stated staff were expected to clean and disinfect the monitors after each use with disinfecting wipes from purple, grey, or orange-topped canisters and that hand wipes were not to be used. The facility’s QA/QC reference manual for the Assure Platinum system identified the use of EPA-registered disinfectant detergent or germicide wipes, and the facility policy stated glucometers were to be cleaned after every use for shared machines and at least weekly if for an individual resident, using Sani-Cloth wipes with a purple cap and not alcohol wipes.
IV Pole and Tube Feeding Equipment Not Kept Clean
Penalty
Summary
The facility failed to maintain resident equipment cleanliness of an IV pole for one resident receiving tube feeding. The resident had severe cognitive impairment and was dependent on staff for ADLs. The resident’s diagnoses included dysphagia following stroke, hypertension, gastrostomy tube feeding, hemiplegia and hemiparesis following stroke, and encephalopathy. On 3/17/26, the IV pole in the resident’s room with the tube feeding pump attached was observed to have a tan-colored dried substance dripping down the pole, covering all five legs, with several dried spots on the floor below. Follow-up observations on 3/18/26 and 3/19/26 continued to show the same dried tan-colored substance on the IV pole, pole legs, and floor. An RN stated the poles should be cleaned of any formula spills as soon as seen and when starting or stopping the feeding for infection control reasons. A nurse manager stated the pumps and poles should be cleaned whenever anything is observed on them, and that the pole and floor should have been taken care of for cleanliness and infection control purposes. The facility policy for tube feedings indicated the IV stand and pump were to be wiped down daily with a cloth dampened with disinfectant.
Resident Lacked Functioning Call Light for Weeks
Penalty
Summary
The facility failed to provide a functioning call light to a resident, identified as R2, for an unknown number of weeks. R2, who was initially independent with toileting, became frequently incontinent and required moderate assistance with toileting over time. Despite the care plan indicating that the call light should be accessible and within reach, R2 did not have a call light within reach during observations. The call light box in R2's room had space for two extension cords, but only one was connected to the roommate's bed, leaving R2 without a call light. R2 reported that he had been using his roommate's call light and had informed maintenance about the issue, but no resolution was provided. Interviews with various staff members, including registered nurses and nursing assistants, revealed that they were aware of the protocol to contact maintenance if a call light was malfunctioning. However, there was no record of maintenance logs or call light logs for R2's room for the two weeks leading up to the survey. The interim nurse manager and the director of nursing confirmed that every resident should have a functioning call light, but R2's issue had not been addressed until the survey. The facility's policy from 2017 also stated that every resident must have a functioning and accessible call light, which was not adhered to in R2's case.
Grievance Form Accessibility and Anonymity Deficiency
Penalty
Summary
The facility failed to ensure that grievance forms and procedures were readily accessible and visible to residents and their representatives, which is a violation of residents' rights to voice grievances without discrimination or reprisal. During a resident council meeting, four residents expressed their lack of awareness on how to file a grievance form. One resident believed a form was available at the front door but was unsure if it could be completed without assistance from a nurse. Observations revealed that the 340 wing had a slot for grievance forms, but no forms were present, and a registered nurse confirmed that forms were not kept on that wing. Interviews with staff, including guest services and the social services director, indicated that grievance forms were only available on the first floor and required residents to request them. The forms had to be handed to a nurse or social services, with no option for anonymous submission. The facility's grievance policy, last updated in 2017, did not include provisions for anonymous filing. The administrator confirmed the lack of anonymous submission options, stating that forms could be left in common areas but not in designated anonymous boxes.
Failure to Conduct Timely Care Conferences
Penalty
Summary
The facility failed to conduct care conferences with residents and/or their representatives, which are essential for reviewing and revising care plans. This deficiency was identified for five residents, each with varying medical conditions such as Alzheimer's disease, dementia, depression, chronic kidney disease, diabetes, congestive heart failure, hemiplegia following a stroke, and renal failure. The care plans for these residents indicated that their wishes and code status should be reviewed at quarterly care conferences, but these meetings were not held as required. For instance, one resident with Alzheimer's and other conditions had not had a documented care conference for 18 months, despite being cognitively intact and able to participate in such meetings. Another resident with hemiplegia and depression had a care conference note documented months after the meeting occurred, without indicating it was a late entry. Additionally, a resident with severe cognitive impairment and end-stage kidney disease had only one care conference documented, and their family member reported difficulty in scheduling further meetings. The facility's social services staff were responsible for scheduling and documenting these conferences but failed to do so consistently. The Director of Nursing was unaware of the lapses until they were brought to her attention, and the facility's policy on care conferences was not provided upon request. This lack of timely and documented care conferences indicates a systemic issue in the facility's care planning process.
Lack of Resident Meal Choice in LTC Facility
Penalty
Summary
The facility failed to provide a process by which residents could make their own food selections for meals, affecting six residents reviewed for food. The deficiency was identified through interviews, observations, and document reviews. Residents reported not being given a choice of meals and were unaware of any alternative menus. For instance, one resident with chronic kidney disease and congestive heart failure stated she had not been given a choice of what to eat since her admission and was not aware of any weekly or alternative menus. Another resident with moderately impaired cognition expressed that meals were always a surprise, and he was not given options or aware of a menu. Staff interviews revealed inconsistencies in the meal selection process. A nursing assistant mentioned that residents did not receive a menu ahead of time to make their own food selections, and dietary aides confirmed that no weekly or alternative menus were posted in the dining room. The dietary aide also acknowledged that residents were supposed to have menus in their rooms, but it was unclear if this was consistently done. The facility's policy indicated that residents should be offered an alternate selection of comparable nutritional value if they refused food, but this process was not effectively implemented. During a meeting with the survey team, the facility's administrator, director of nursing, registered dietician, dining services director, and chef confirmed that residents did not select food prior to meal service. Instead, they were given meals based on electronically printed diet slips, and if they did not want the meal, something else would be made for them. The dining services director stated that making different meals for many residents was not feasible, leading to the current practice of serving the menu item first and then offering alternatives if needed. This approach resulted in residents feeling they had no choice in their meals, contributing to the deficiency.
Failure to Complete PASARR for New Mental Health Diagnoses
Penalty
Summary
The facility failed to complete a Level II Preadmission Screening and Resident Review (PASARR) for a resident who was diagnosed with new mental health conditions. The resident, who was originally admitted with diagnoses including malnutrition, failure to thrive, anxiety, and repeated falls, was later diagnosed with delusional disorders, major depressive disorder, and borderline personality disorder. Despite these new diagnoses, no updated PASARR screening was conducted, as indicated by the record review. Interviews with facility staff revealed a gap in the system for ensuring new PASARR screenings were completed following new mental health diagnoses. The social services staff member was unsure who was responsible for completing the PASARR, while the administrator acknowledged the lack of a process for updating screenings after new diagnoses. The facility's PASRR Screening policy required compliance with regulations for screening and updates for individuals with mental illness, but this was not followed in this case.
Failure to Provide Resident with Preferred Activities Due to Language Barrier
Penalty
Summary
The facility failed to ensure that a resident's preferred activities for individual entertainment were offered, specifically for a resident who spoke only Spanish and had moderate cognitive impairment. The resident, who was admitted with diagnoses including dementia, anxiety, and depression, expressed a preference for activities such as listening to music and going outside. However, the facility did not provide activities in Spanish, and there was no documentation of activities being offered, participated in, or refused by the resident. Interviews with staff revealed that the therapeutic recreation (TR) staff were expected to offer activities to the resident using an interpreter phone, but this was not done. The TR director confirmed that an individualized preference for activities was not completed for the resident, and there was no documentation of activities being offered or refused. The resident expressed feeling isolated and like a "bird in a cage" due to the lack of activities and communication barriers. The facility's Life Enrichment Activities policy emphasized the importance of meaningful activities designed to promote quality of life and resident engagement. Despite this, the facility did not implement activities or programs specific to the resident's language needs, and staff were unaware of the resident's participation in activities. The lack of Spanish-speaking activities and failure to document activity offerings or refusals contributed to the deficiency.
Failure to Reposition High-Risk Resident
Penalty
Summary
The facility failed to provide timely repositioning for a resident, identified as R58, who was at high risk for pressure ulcers. R58 had a history of dementia, aphasia, diabetes mellitus, and chronic kidney disease, and was dependent on staff for repositioning due to impaired mobility. The resident had an unstageable pressure ulcer on the right heel, covered by slough, and was identified as being at risk for further skin breakdown. The care plan for R58 required repositioning every two hours, but observations revealed that this was not consistently followed. On multiple occasions, R58 was observed seated in a Broda chair for extended periods without repositioning. Despite having a care plan that mandated repositioning every two hours, staff interviews confirmed that R58 was not repositioned as required. For instance, on the morning of January 8th, R58 remained in the same position from 7:11 a.m. until 10:28 a.m. without any position changes, contrary to the care plan directives. This lack of adherence to the care plan was acknowledged by the nursing staff, who confirmed the discrepancy between the care plan and the actual care provided. The facility's Skin Integrity Management policy emphasized the importance of identifying residents at risk for pressure ulcers and implementing individualized interventions. However, the failure to reposition R58 as per the care plan indicates a lapse in following these guidelines. The director of nursing expected the care plan to be followed, but the observations and staff interviews highlighted a gap in the execution of the care plan, leading to the deficiency in providing appropriate pressure ulcer care for R58.
Infection Control Deficiency Due to Improper PPE Use
Penalty
Summary
The facility failed to adhere to CDC guidelines for infection prevention and control, specifically in the use and disposal of personal protective equipment (PPE). Observations revealed that a nursing assistant (NA) did not discard PPE before leaving the rooms of residents who were under isolation precautions. The NA was seen wearing the same PPE when moving between rooms and only doffing the equipment in the hallway, contrary to the facility's policy that requires PPE to be removed before exiting the room. Additionally, the facility did not follow enhanced barrier precautions (EBP) for a resident with an indwelling medical device. A registered nurse (RN) and nursing assistants were observed providing care without wearing gowns, which is required for high-contact activities under EBP. The RN administered medication and checked blood sugar without a gown, while the nursing assistants performed personal care activities without the appropriate PPE. Interviews with staff, including the infection preventionist and director of nursing, confirmed that the facility's policy mandates the use of gowns and gloves for EBP patients during high-contact care. However, staff members were not consistently following these protocols, leading to a failure in implementing effective infection control measures.
Failure to Administer Pneumococcal Vaccinations per CDC Guidelines
Penalty
Summary
The facility failed to ensure that three residents, aged 83 and 84, received pneumococcal vaccinations in accordance with the CDC recommendations. The CDC guidelines specify that adults aged 65 and older who have previously received the PPSV23 or PCV13 vaccines should receive a dose of the PCV20 vaccine at least one year after the most recent PPSV23 or PCV13 vaccine. Additionally, adults who have received both PCV13 and PPSV23 at age 65 or older should receive a dose of PCV20 at least five years after the last pneumococcal vaccine dose, based on shared clinical decision-making. However, the medical records for these residents lacked documentation indicating that they had been offered or received the PCV20 vaccine based on shared clinical decision-making. During an interview, the infection preventionist confirmed the findings and stated that the facility follows CDC guidelines for pneumococcal immunizations. The Director of Nursing expressed that her expectations were for residents to receive immunizations following these guidelines. Despite the facility's policy to reduce the incidence of pneumococcal disease by offering and providing vaccinations according to CDC and MDH recommendations, the records for the three residents did not reflect adherence to these guidelines, indicating a deficiency in the facility's vaccination protocol.
Failure to Notify Physician of Significant Weight Gain in CHF Resident
Penalty
Summary
The facility failed to provide timely notification to the physician regarding a significant change in condition for a resident diagnosed with congestive heart failure (CHF). The resident, who had intact cognition, was admitted with a weight of 249 pounds and had orders for daily weight monitoring with instructions to notify the provider if there was a weight gain of three pounds in a day or five pounds in a week. Despite a weight gain of 16 pounds over six days, the nursing staff did not notify the provider. The resident expressed concerns about weight gain and swelling, but the provider was not informed until the resident and family raised concerns directly with the nurse practitioner on a later date. The resident's care plan and physician orders clearly outlined the need for immediate notification in case of significant weight gain, which was not adhered to by the nursing staff. A licensed practical nurse acknowledged the expectation to monitor for symptoms such as edema and shortness of breath and to notify the provider of any changes, but documentation of such notification was absent. A registered nurse admitted to planning to reweigh the resident and notify the provider but failed to do so due to being busy. Consequently, the resident was sent to the hospital for CHF exacerbation after the nurse practitioner assessed the situation.
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What surveyors actually found near you
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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 Louis Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Estates At St Louis Park Llc | 0.7 mi | ★★★★★ | 0 | 0 |
| Augustana Chapel View Care Center | 0.9 mi | ★★★★★ | 6 | 0 |
| The Villas At The Cedars | 1.2 mi | ★★★★★ | 15 | 1 |
| The Villas At St Louis Park | 1.8 mi | ★★★★★ | 18 | 0 |
| Hopkins Restorative Care Center | 1.9 mi | ★★★★★ | 23 | 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.