Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Gertrudes Health & Rehabilitation Center during CMS and state inspections, most recent first.
Food storage, hair/beard net use, and dish machine monitoring deficiencies were identified in the kitchen. Uncovered, unlabeled hamburger patties and fish filets were found in the walk-in freezer, scoops were stored inside bulk flour and rice containers, and staff were observed working without hair or beard nets in food prep and dish areas. The dish machine log had multiple missing entries, and staff used the machine while wash temps were below the required level.
A resident who was cognitively intact and receiving albuterol sulfate via nebulizer was observed self-administering the treatment, but the EMR lacked both a self-administration assessment and a physician order for that respiratory medication. The care plan called for independent respiratory treatments with nurse assistance for setup and cleaning, and an LPN and the ADON confirmed the resident was being allowed to self-administer without the required order and assessment.
Call Light Not Kept Within Reach: A resident with impaired cognition, limited mobility, and multiple diagnoses including HF, kidney disease, arthritis, depression, and anxiety was observed lying in bed with the call light out of reach on the nightstand. The resident stated she could not see it and needed help getting up for dinner, while an NA confirmed it was out of reach. Staff and the DON stated the call light should always be within reach, and facility policy required the call system to be accessible while residents are in bed.
A resident with a stroke diagnosis and intact cognition reported that his room was cold and was observed wearing a winter coat while sitting in his recliner. Although the wall thermostat showed temperatures in the low 70s, surveyor measurements in the resident’s usual sitting area were repeatedly in the mid-to-high 60s and later below the required range. Staff acknowledged the complaint, and the DOM confirmed the room temperatures were not within the required 71 to 81 degrees Fahrenheit range.
Psychotropic medication use was not properly supported or monitored for two residents. One resident received aripiprazole for hallucinations even though the MDS showed no hallucinations or delusions and the pharmacist noted there was no allowable diagnosis to support the antipsychotic. Another resident received aripiprazole for recurrent major depressive disorder, but the MAR/TAR and EMR lacked documentation of the required monthly orthostatic blood pressures, even though staff signed the checks as completed and the DON confirmed the monitoring was not found.
A resident who was cognitively intact and needed assistance with toileting and bathing strongly preferred female-only caregivers, but this preference was not included in the care plan or care guide sheets. Staff said the preference was shared informally by word of mouth, while the clinical manager was unaware of it and the resident reported that male staff continued to enter the room and she had to remind them of her preference.
Failure to Provide Routine Nail Care for a Dependent Resident: A resident who was dependent on staff for ADLs and had arthritis did not routinely receive fingernail or toenail care. Weekly skin checks did not document nail care, the chart did not show refusal, and staff were unsure when nail trimming was last completed. On observation, the resident said her toenails needed trimming, and they were seen extending past the toes with some curling.
A resident who received dialysis three times weekly had orders to monitor the fistula and assess for symptoms before treatment, and the care plan directed staff to obtain the dialysis care plan and communication sheet and check for dialysis orders or changes. However, the resident’s record contained only one dialysis run sheet in the EMR and the most current paper run sheet was months old. Staff reported the dialysis sheet was sent with the resident but often did not come back, and the ADON and DON confirmed ongoing communication breakdowns with the dialysis provider.
A resident who required two-person assistance and a mechanical lift for transfers was physically abused by a nursing assistant who attempted to transfer the resident alone and without the required equipment. During the incident, the NA punched the resident in the knee after a verbal altercation, which was witnessed by an RN. The resident reported feeling unsafe and described the abuse, and the facility's investigation confirmed that the NA did not follow the care plan or established protocols.
A facility failed to thoroughly investigate an allegation of physical abuse when a cognitively intact resident was punched by a nursing assistant during care. Although staff interviews were conducted, no residents or families were interviewed about the incident, and the investigation did not include residents from other units where the staff member had worked. The facility's policy requiring comprehensive interviews was not followed.
A resident who required transfer with a Sara Steady lift and care in pairs due to behavioral and physical needs was transferred by staff without the required device and without a second staff member present. Staff interviews revealed confusion and lack of awareness regarding the care plan interventions, and documentation gaps contributed to inconsistent care. The resident had multiple medical conditions and was dependent on staff for daily activities.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes that affected the resident, as required by regulations.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to meet individualized care requirements.
A resident with multiple health issues, including end-stage renal disease and severe osteoporosis, experienced a fractured clavicle after a transfer using a sit-to-stand lift. The facility failed to report the injury of unknown origin to the State Agency within the required timeframe. Staff interviews revealed inconsistencies in the incident's account, and the facility's administrator acknowledged the reporting failure.
A resident with bilateral amputations expressed feeling unsafe in a shower chair, preferring showers over bed baths. Despite available mechanical lifts and slings, the LTC facility failed to reassess or accommodate the resident's bathing preference, leading to a deficiency in promoting resident self-determination.
The facility failed to provide routine grooming for two residents dependent on staff for personal care. One resident with impaired cognition had unaddressed chin hairs, while another with intact cognition had two-inch throat hairs that were not trimmed or shaved since admission. Staff interviews confirmed that personal care, including shaving, should be offered daily, but these needs were neglected.
A resident with moderate cognitive impairment experienced ongoing constipation issues that were not adequately addressed by the facility. Despite being on medications like Miralax and Senna-S, the resident reported infrequent bowel movements and a lack of proactive management discussions with staff. Medical records were incomplete, and staff interviews revealed a failure to communicate and document the resident's bowel status, leading to a deficiency in bowel management.
A resident with intact cognition and urinary retention had an indwelling catheter since the previous fall, but the facility failed to assess its removal or consult urology. Despite the resident's goal to have the catheter removed, no toileting program or alternative methods were implemented. Interviews revealed a lack of documentation and discussion with the resident and family about the catheter's duration or alternatives, contrary to the facility's policy on catheter use.
A resident with dementia, anxiety, and depression experienced behavioral issues after discontinuing Zoloft. Despite repeated recommendations from the consulting pharmacist to consider restarting Zoloft or using Lexapro, the facility failed to act on these suggestions in a timely manner. The nurse practitioner did not provide a documented rationale for not following the pharmacist's advice, and Lexapro was only started after increased communication from the care team about the resident's symptoms.
A resident in an LTC facility did not receive prescribed medications due to unavailability, resulting in a 7.14% medication error rate. The resident was discharged with orders for droxidopa and metronidazole, but these were not administered as the medications were not in the cart. The LPN did not inform the RN, and the pharmacy was not contacted. The DON noted a lack of clarity on how the orders were missed, and the facility's policy did not define medication errors or actions for unavailable medications.
The facility did not ensure that survey results and the plan of correction for the past three years, including the most recent survey from December 2023, were accessible to residents, families, and visitors. A binder at the main entrance was missing these documents, and the administrator confirmed the oversight. No facility policy on posting survey results was provided.
Food Storage, Hair/Beard Net Use, and Dish Machine Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to store frozen food items in a manner that reduced the risk of cross contamination in the walk-in freezer. During the initial kitchen tour on 1/12/26, one speed rack contained 2 trays of uncovered, unlabeled, uncooked hamburger patties, and another speed rack contained 1 tray of 15 uncooked fish filets that were also uncovered and unlabeled. The food service director later stated that storing uncovered food in the freezer was unsanitary and that all items on the speed racks should be individually covered or covered with a proofing bag. The facility also failed to keep scoops out of bulk food containers. During the same kitchen tour, a triple bulk container used for flour, white rice, and brown rice had debris on the lids, and scoops were observed inside the flour and white rice bins. The food service director stated the scoops should not be left inside the containers because of concern for cross contamination. The administrator also stated the scoops should be stored outside of the containers. In addition, the facility did not consistently monitor dish machine temperatures and did not ensure hair and beard nets were used in food preparation and utensil sanitizing areas. The January 2026 dish machine log had multiple missing temperature entries, and staff were observed using the machine while wash temperatures were below the required 160 degrees F on more than one occasion. A dietary aide was observed sanitizing and storing dishes and cookware without a hair net, and a cook with a beard was observed setting up the steam table and handling buns without a beard net until he later asked where to find one. The food service director stated staff knew better and that hair and beard nets were expected, and the administrator stated she expected staff to wear them as standard practice.
Missing order and assessment for self-administration of nebulizer medication
Penalty
Summary
The facility failed to ensure a resident was appropriately assessed and had an appropriate order in place to self-administer nebulizer medication for one resident reviewed for self-administration of medications. The resident’s significant change MDS indicated the resident was cognitively intact and required partial to moderate assistance with most ADLs. The resident had active orders for albuterol sulfate via nebulization once daily in the morning and three times daily as needed for difficulty breathing, shortness of breath, wheezing, and/or bronchospasm prevention. The resident’s care plan stated the resident would independently administer respiratory treatments as ordered and receive assistance setting up, disassembling, and cleaning respiratory equipment from a licensed nurse, with interventions to obtain a physician order for self-administration of respiratory treatments and perform a self-administration medication assessment per facility protocol. However, the electronic medical record lacked both an order and an assessment for self-administration of the respiratory treatments. An LPN stated the resident administered the nebulizer independently, and observation showed the LPN handed the resident the mouthpiece already filled with albuterol, turned on the nebulizer machine, and left the resident to self-administer the medication. The ADON confirmed there was not an order or assessment in place for self-administration and that these would be expected before self-administration of any medications.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to accommodate resident needs by not ensuring the call light was accessible for one resident who was reviewed for call lights. The resident’s quarterly MDS identified impaired cognition, no rejection of cares or wandering, impaired lower extremity range of motion, use of a walker or wheelchair for mobility, and need for partial to moderate assistance with dressing, transfers, and hygiene. Diagnoses included heart failure, kidney disease, arthritis, depression, and anxiety. During observation and interview, the resident was lying in bed with the call light out of reach on the nightstand next to the head of the bed and stated she could not see it and wanted assistance to get up for dinner. She said she normally uses the call light if she needs help, but if it is out of reach she makes noise to get staff attention. A nursing assistant verified the call light was out of reach and stated it should be in reach to ask for help. Other staff and the DON stated the call light should be placed within reach at all times, and the facility policy stated the call system must be accessible to residents while in bed or other sleeping accommodations.
Resident Room Temperature Not Maintained Within Required Range
Penalty
Summary
The facility failed to ensure resident rooms were maintained at a comfortable temperature between 71 and 81 degrees Fahrenheit for one resident, R57, who reported that his room was cold. R57’s admission MDS, dated 12/22/25, indicated a diagnosis of cerebral infarction (stroke) with intact cognition. During an interview on 1/12/26, R57 stated he was cold, was observed wearing a winter coat while sitting in a recliner in his room near the window, and said he spent most of his time there. He reported that he had told staff about the cold room and was told the room is always like this. The thermostat on the wall showed 72.9 degrees Fahrenheit, but surveyor-obtained temperatures in the resident’s room were lower, including 66.2 degrees by the TV, 68.3 degrees around the chair, and 67.7 degrees between the chair and the wall. R57 continued to report that the room was cold, stating on 1/13/25 that he did not use his personal refrigerator because the room was cold enough to keep items on the counter cold. On 1/14/26, the surveyor again measured the room temperature around R57’s chair at 66.5 degrees Fahrenheit. During interviews, the NA stated R57 had complained about the room being cold about a week earlier and that a form had likely been completed for maintenance. The DOM later stated he had received a complaint the prior week, had a vendor evaluate the room, and checked the temperature through the computer, which indicated it was above 71 degrees Fahrenheit; however, when the DOM and surveyor measured the room together, the area around R57 was 69.7 degrees Fahrenheit and the middle of the room was 70.2 degrees, while the thermostat read 72.3 degrees. The administrator stated room temperatures are to be between 71 and 81 degrees Fahrenheit, and the facility did not provide a room temperature policy.
Psychotropic Medication Lacked Supporting Diagnosis and Required Monitoring Was Not Documented
Penalty
Summary
The facility failed to provide and document an appropriate diagnosis for a prescribed psychotropic medication for one resident. The resident’s quarterly MDS indicated intact cognition and no hallucinations or delusions during the look-back period, yet the physician order report showed aripiprazole (Abilify) 5 mg daily ordered for bothersome and frightening hallucinations. The consultant pharmacist later noted the resident was receiving aripiprazole but lacked an allowable diagnosis to support its use, and the nurse practitioner discontinued the medication after reviewing that recommendation. During interview, the ADON stated nurse managers were expected to review psychotropic medications for an appropriate diagnosis when ordered and confirmed the medication did not have an appropriate diagnosis attached. The facility also failed to provide appropriate side effect monitoring for another resident receiving an antipsychotic medication. The resident’s admission MDS showed intact cognition, no hallucinations or delusions, no behavioral symptoms, and that the resident received an antipsychotic medication. The January and December MAR/TARs documented daily aripiprazole 10 mg for moderate recurrent major depressive disorder and included monthly orthostatic blood pressure orders related to antipsychotic use, with signatures indicating completion, but the records lacked the actual blood pressure documentation. The resident’s blood pressure and pulse logs and progress notes also lacked evidence that orthostatic blood pressures were completed and documented. During interview, an LPN verified the orthostatic blood pressure orders were signed off as completed but no blood pressures were documented in the MAR/TAR or vital signs section of the EMR. The DON stated the expectation was that any resident on an antipsychotic medication should receive monthly orthostatic blood pressures and confirmed no such documentation could be found for the resident in the last few months. The facility policy stated psychotropic medications are ordered to treat a specific condition as diagnosed and documented in the medical record, and that when psychotropic medications are ordered, the IDT identifies target behaviors and medication side effects to be monitored.
Failure to Care Plan Resident Preference for Female-Only Caregivers
Penalty
Summary
The facility failed to ensure that a resident’s preferences were care planned so they could be honored for one resident who preferred female-only caregivers. The resident’s admission MDS indicated the resident was cognitively intact and required substantial assistance with toileting and partial to moderate assistance with bathing. A progress note on admission documented that the resident strongly preferred female caregivers and stated that if female support was not available, the resident would do it independently. However, the resident’s care plan and care guide sheets did not include this preference. During interviews, the resident stated that multiple staff members had been told several times about the preference for female caregivers, but male staff continued to enter the room and the resident had to remind them of the preference. A NA stated that when a resident voiced a preference such as female-only caregivers, staff passed it along shift to shift by word of mouth. The clinical manager stated she was unaware of the preference and would have expected it to be communicated so it could be care planned, while the LSW stated the preference had been communicated from the hospital before admission. The SSD stated such preferences were expected to be communicated to the nurse manager and care planned because staff float between units, and the facility policy required the comprehensive assessment and care plan to include a resident’s customary routine and preferences.
Failure to Provide Routine Nail Care for a Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident who was dependent on staff for activities of daily living routinely received fingernail and toenail care. The resident’s MDS indicated intact cognition, arthritis, and dependence on staff for toileting hygiene, lower body dressing, and putting on and taking off footwear. The care plan identified self-deficits with ADLs including grooming, bathing, and oral care, but the medical record did not show that the resident had refused toenail care. Weekly skin checks repeatedly documented nail care as either not necessary or left blank, and there was no documentation showing that nail care had been completed. During observation, the resident stated her toenails needed to be trimmed and said she did not think anyone had offered to help since her admission. Her toenails were observed to extend past the ends of her toes, with varying nail length and some curling. Staff interviews confirmed they were unsure when nail care had last been done, that the resident had not been offered toenail trimming, and that documentation of nail care or refusals was expected but not found in the record.
Failure to Maintain Dialysis Communication and Collaboration
Penalty
Summary
The facility failed to maintain communication and collaboration with the dialysis provider for a resident who received dialysis three times a week. The resident was admitted on 5/10/24, was cognitively intact, required substantial to maximum assistance with activities of daily living, and had orders dated 11/20/25 directing staff to monitor the dialysis fistula and document vital signs and symptoms such as shortness of breath, chest pain, nausea, vomiting, or seizure activity prior to dialysis. The resident’s care plan, dated 5/13/24, directed staff to obtain the dialysis care plan and coordination of care communication sheet and to check for orders or changes from the dialysis unit. The resident’s electronic medical record contained only one dialysis communication sheet, dated 10/15/25, while the paper record contained multiple dialysis communication sheets, with the most current dated 8/25/25. Staff stated the resident left for dialysis around 5:00 a.m. and returned around 10:00 a.m., and that an envelope with the dialysis communication sheet was sent with the resident, but the facility often did not receive the sheet back. The ADON stated staff were expected to send the dialysis communication sheet to dialysis and review it when the resident returned, but confirmed the most current sheet in the record was from October and said, "we send the sheet and it doesn't always come back." The DON also confirmed nurses were expected to follow up with the dialysis communication sheets and stated, "we try our best but there is always communication breakdown."
Failure to Protect Resident from Physical Abuse During Transfer
Penalty
Summary
A deficiency occurred when a nursing assistant (NA) physically abused a resident during care. The resident, who was cognitively intact and dependent on staff for most activities of daily living, required the use of a mechanical lift for transfers and was to receive care from two staff members at all times. Despite these care plan requirements, the NA attempted to transfer the resident alone and without the mechanical lift, leading to an altercation. During this incident, the NA was witnessed by a registered nurse (RN) punching the resident in the left knee after a verbal argument and alleged aggression from the resident. The resident reported feeling unsafe and described being punched by the NA while being transferred from bed to wheelchair. The resident demonstrated the action to interviewers and stated that he retaliated by hitting the NA back. The RN corroborated the resident's account, stating she heard yelling, entered the room, and observed the NA strike the resident. The NA admitted to being alone with the resident, not using the required lift, and not following the care plan, citing lack of time to read care plans and being unfamiliar with the resident's needs. The facility's investigation confirmed that the NA failed to follow the care plan, which required two staff for care and use of the mechanical lift. The NA was alone with the resident and did not adhere to established protocols for managing residents with behavioral concerns. The incident was substantiated as physical abuse, with both the resident and RN providing consistent accounts of the event.
Failure to Thoroughly Investigate Alleged Physical Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of witnessed physical abuse involving a resident who was cognitively intact and dependent on staff for most activities of daily living. The incident occurred when a nursing assistant (NA) was observed by a registered nurse (RN) to punch the resident in the leg during care. The resident confirmed feeling unsafe and described being struck by the NA, and both the NA and RN provided statements regarding the incident. Despite this, the facility's investigation did not include interviews with other residents to determine if they had experienced or witnessed abuse. The investigation process involved interviewing staff members about general experiences with mistreatment but did not include specific questions about the incident or the staff involved. Sixteen staff members were asked if they had ever mistreated a resident or witnessed mistreatment, but there was no documentation of targeted questions regarding the alleged abuse involving the NA and the resident. Additionally, the investigation did not include interviews with residents from other units where the NA had worked, nor were families interviewed. The facility limited its resident assessment to skin and pain checks and baseline emotional and psychological observations, without directly asking residents about abuse or safety concerns. The director of nursing and the administrator indicated that residents on the cognitive unit were not interviewed due to concerns about their ability to provide accurate responses, and residents from other units were not interviewed because the incident was considered isolated. The facility's policy required interviewing all individuals who might have knowledge of the incident, including the alleged victim, perpetrator, witnesses, or others with related contact, but this was not followed in the investigation.
Failure to Implement Care Plan Interventions for Transfer and Supervision
Penalty
Summary
The facility failed to implement the care plan interventions for a resident who required specific transfer and supervision protocols. The resident's care plan indicated that all transfers from bed to chair or toilet were to be performed using a Sara Steady mechanical lift and that care was to be provided in pairs (two staff members present) due to previous behavioral concerns and accusations made by the resident. Despite these documented interventions, staff were observed transferring the resident without the required mechanical device and without a second staff member present. Additionally, there was confusion among staff regarding the specifics of the care plan, with some staff unaware of the need for paired care or the use of the Sara Steady lift. Interviews revealed that staff did not consistently read or follow the care plan, leading to inconsistent application of required interventions. One nursing assistant admitted to transferring the resident alone and without the mechanical lift, stating she had not reviewed the care plan prior to providing care. Other staff members, including nurses and therapy staff, expressed uncertainty about the requirements for paired care and whether these applied to their roles. Documentation and communication gaps were evident, as some staff relied solely on the treatment administration record (TAR) and did not routinely review the full care plan, resulting in missed interventions. The resident involved had a history of sepsis, alcohol-induced chronic pancreatitis, lymphedema, and osteoarthritis, and was dependent on staff for most activities of daily living. The care plan also noted behavioral concerns, including making accusations against staff of different ethnicities, which contributed to the requirement for care in pairs. Despite these needs, the facility did not ensure that all staff were aware of or adhered to the care plan interventions, leading to the observed deficiencies in care delivery.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as mandated by regulations.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with established directives or the expressed wishes and objectives of the resident, resulting in noncompliance with required standards for individualized care.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency within the required timeframe for a resident who was assessed with a fractured clavicle. The incident involved a resident who was cognitively intact and dependent on staff for all transfers. The resident had a history of congestive heart failure, end-stage renal disease, malnutrition, respiratory failure, and morbid obesity. On the evening of the incident, the resident was assisted by staff using a sit-to-stand lift for toileting. During the transfer, the resident's legs became weak, and she was lowered to the toilet. Later, the resident experienced severe pain and was sent to the emergency department, where an x-ray revealed a fractured clavicle. Interviews with staff revealed inconsistencies in the account of the incident. The night nurse reported that the resident had slid in the sit-to-stand lift earlier in the evening, while the evening nurse stated that the resident was weak and requested the use of a ceiling lift due to fear of falling. The nursing assistants involved in the transfer did not recall the resident sliding or bumping her body during the transfer. The facility's assistant director of nursing and the medical director provided possible explanations for the fracture, citing the resident's severe osteoporosis and vulnerability to fractures with slight movements. The facility's administrator acknowledged that the injury should have been reported as an injury of unknown origin within 24 hours, but believed it was reasonable to assume the fracture occurred during the transfer. The facility's policy on abuse prevention required reporting serious bodily injury immediately, but no later than two hours after the event. The report highlights the facility's failure to adhere to this policy, as the injury was not reported to the State Agency within the required timeframe.
Failure to Assess and Facilitate Resident's Bathing Preference
Penalty
Summary
The facility failed to assess and accommodate a resident's preference for bathing methods, specifically showers, after the resident expressed feeling unsafe being transported in a shower chair. The resident, who had undergone bilateral below-knee amputations, was receiving weekly bed baths but preferred showers. The resident felt uncomfortable and unsafe being wheeled through public spaces in a shower chair due to his amputee status. Despite the resident's expressed discomfort, the facility did not reassess or explore alternative options to facilitate the resident's preference for showers. Interviews with staff revealed a lack of communication and assessment regarding the resident's discomfort with the shower chair. A nursing assistant mentioned offering showers, but the resident refused without explaining why. The unit manager acknowledged the resident's discomfort but did not investigate further, believing it was not her place to ask for more information. The director of nursing stated that an assessment should have been conducted to understand the resident's concerns and offer suitable options. The facility had mechanical lifts and slings available that could potentially address the resident's needs, but these were not utilized or considered in the resident's care plan.
Failure to Provide Routine Grooming for Residents
Penalty
Summary
The facility failed to ensure routine grooming was offered or provided to promote good hygiene for two residents who were dependent on staff for their care. Resident 1 (R1) was identified with impaired cognition and multiple diagnoses, including heart disease and diabetes, and was dependent on staff for personal hygiene. Observations revealed that R1 had multiple white hairs on her chin, which had not been addressed by the staff. Interviews with nursing assistants confirmed that personal care, including shaving, should be offered daily, but it appeared that R1's grooming needs had been neglected for at least a couple of weeks. Resident 25 (R25), who had intact cognition and required assistance with personal hygiene, was observed with two-inch white hairs extending from her throat. R25 expressed a desire to have the hairs removed and stated that no one from the facility had offered to trim or shave them since her admission. Interviews with staff, including a licensed practical nurse and the director of nursing, acknowledged that personal hygiene care should include shaving and be performed at least twice per day. However, it was evident that R25's grooming needs had been overlooked, as she had not been asked about the hairs or offered assistance with their removal.
Deficiency in Bowel Management for Resident
Penalty
Summary
The facility failed to adequately address and assess complaints of potential constipation for a resident, leading to a deficiency in bowel management. The resident, identified as having moderate cognitive impairment, reported ongoing issues with constipation despite being on medications like Miralax and Senna-S. The resident expressed that staff had not discussed proactive bowel management options with him, despite his history of colon polyps and repeated complaints to staff about constipation. The resident's medical records, including the Elimination - Bowel evaluation and Medication Administration Record (MAR), were incomplete and lacked comprehensive assessments or interventions for bowel management. The MAR showed multiple refusals or non-administrations of bowel-related medications, and a bowel assessment order was recorded late without further action. Nursing staff, including a nursing assistant and a registered nurse, acknowledged the resident's complaints but failed to ensure appropriate follow-up or documentation in the medical record. Interviews with facility staff, including a licensed practical nurse unit manager and the director of nursing, revealed a lack of communication and documentation regarding the resident's bowel status. The Elimination-Bowel tool was not completed, and standing orders for bowel management were not enacted or charted. The director of nursing confirmed the importance of assessing and acting upon bowel complications to prevent impaction, but the facility's records did not reflect such actions. Additionally, the facility did not provide a policy on bowel management when requested.
Failure to Assess and Remove Indwelling Catheter
Penalty
Summary
The facility failed to assess and remove an indwelling urinary catheter for a resident, identified as R27, who was admitted with intact cognition and required assistance with toileting. Despite having a Foley catheter since the previous fall due to urinary retention, the facility did not attempt to implement a toileting program or consult with urology to evaluate the necessity of the catheter. The resident expressed a desire to have the catheter removed to return home, but no assessment or alternative methods were pursued by the facility. Interviews with the health unit coordinator and the director of nursing revealed that there was no order for a urology consult in the resident's electronic medical record, and no discussion had taken place with the resident or their family regarding the catheter's duration or alternatives. The facility's policy on preventing catheter-associated urinary tract infections emphasized eliminating indwelling catheters whenever possible, yet this was not adhered to in R27's case.
Failure to Act on Pharmacist's Recommendations for Resident's Medication
Penalty
Summary
The facility failed to ensure that the consulting pharmacist's recommendations were fully addressed or acted upon for a resident, identified as R66, who was reviewed for unnecessary medication use. R66's quarterly Minimum Data Set assessment indicated no cognitive impairment, hallucinations, delusions, or behaviors during the seven-day look-back period, but the resident was diagnosed with dementia, general anxiety disorder, and depression. The consulting pharmacist made several recommendations to consider restarting Zoloft or using a different SSRI like Lexapro due to reported behavioral issues after Zoloft was discontinued. However, these recommendations were not acted upon in a timely manner, and there was a lack of documented rationale for not following the pharmacist's advice. The nurse practitioner acknowledged the pharmacist's recommendations but did not make changes to the medication regimen, citing previous side effects and a recent hospitalization for psychic behaviors. Despite repeated recommendations from the pharmacist in August and September, there was no provider response or documented rationale for not acting on the advice to consider Lexapro. It was only after increased communication from the care team about R66's symptoms of anxiety and depression that Lexapro was started at the end of October. Interviews with facility staff, including the director of nursing and the nurse practitioner, revealed that the process for reviewing and acting upon pharmacy recommendations was not followed. The director of nursing confirmed that the pharmacy recommendations should have been reviewed and addressed during the next month's pharmacy review, but this did not occur for R66. The consultant pharmacist also noted the absence of a documented rationale from the provider for disregarding the recommendations, highlighting a breakdown in communication and follow-up within the facility's medication management process.
Medication Unavailability Leads to Errors
Penalty
Summary
The facility failed to ensure medications were available in a timely manner for a resident, resulting in multiple omitted doses and a medication error rate of 7.14%. The resident, who was discharged from an acute care hospital with a diagnosis of orthostatic hypotension, was prescribed droxidopa and metronidazole. However, upon observation, the medications were not available in the medication cart, and the licensed practical nurse (LPN) confirmed that the medications had not been administered since the resident's admission two days prior. The LPN did not notify the unit manager about the unavailability of the medications, and the registered nurse unit manager (RN) confirmed that the pharmacy had not been contacted. The RN acknowledged that the nurse responsible was new and had not participated in recent training. The consulting pharmacist noted that metronidazole should have been readily available, and the dispensing pharmacy technician confirmed that they had not received the orders for the medications. The director of nursing (DON) explained that the health unit coordinator is responsible for faxing orders to the pharmacy, but it was unclear how the orders were missed. The facility's policy on administering medications lacked definitions of what constituted an error or actions to take when medications were unavailable. The deficiency was identified as a failure to provide medications as ordered, which is crucial to prevent negative outcomes for residents.
Failure to Provide Access to Survey Results
Penalty
Summary
The facility failed to ensure that residents, families, and visitors had access to the survey results and the plan of correction (POC) for the past three years, including the most recent survey from December 2023. During an observation at the main entrance, a binder labeled 'St Gertrude's State Survey Results' was found to be missing the survey results and POC from the recertification survey exited on December 14, 2023. The receptionist indicated that the administrator was responsible for maintaining the binder. Upon review, the administrator confirmed that the survey results from December 2023 were not included in the binder at the reception desk or in another binder that was supposed to contain results from the past year. The administrator acknowledged the oversight and the requirement to have three years of survey results available for review. A facility policy on posting survey results was not provided.
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 892 citations issued within 25 miles in the last 12 months — including the 26 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 Shakopee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shakopee Friendship Manor | 2.7 mi | ★★★★★ | 2 | 1 |
| Auburn Manor | 4.9 mi | ★★★★★ | 8 | 0 |
| Flagstone | 6.5 mi | ★★★★★ | 15 | 0 |
| Minnesota Masonic Home Care Center | 7.7 mi | ★★★★★ | 11 | 0 |
| Friendship Village Of Bloomington | 7.9 mi | ★★★★★ | 13 | 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.