Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 The Villas At St Louis Park during CMS and state inspections, most recent first.
Medication labeling and controlled drug storage deficiencies were identified when multiple insulin pens and an eye drop bottle lacked open dates, expiration dates, or pharmacy labels, and an LPN was unsure how to perform the 3 checks. In addition, two locked metal boxes containing liquid lorazepam intensol were found inside the med room refrigerator, and the DON could not locate keys for the boxes.
Failure to maintain a resident’s facial grooming. A cognitively intact resident with arthritis, stroke, dementia, and upper-extremity impairment was observed with visible chin hair despite needing substantial to max assist with personal hygiene, including shaving. The SW noticed the hair and offered to have her face shaved, and both the resident and FM stated she would have preferred it removed. Staff said shaving was offered during morning grooming, and the DON stated basic grooming and shaving were expected as part of routine care.
A facility failed to complete self-administration medication assessments before allowing two residents to keep and take meds at the bedside. One resident with CHF, CKD, anemia, and hypertensive urgency had multiple med orders but no order or assessment for self-administration, yet unidentified pills/capsules were found on the bedside tray and staff said meds were often left there. Another cognitively intact resident with stroke and Barrett’s esophagus had lozenges in the room despite no provider order for self-administration and a prior assessment stating the resident lacked capacity; RN-A, RN-B, and the DON confirmed the missing order and current assessment.
A resident with intact cognition did not receive a NOMNC at least 48 hours before the end of a Medicare Part A stay. The resident signed the NOMNC less than two days before coverage ended, and the EHR lacked evidence the notice had been provided on time. The BOM and associate administrator confirmed the timing requirement and that the notice should have been given earlier.
Failure to complete regular care conferences for a resident with anxiety, depression, bipolar disorder, and schizophrenia. The resident’s MDS showed she was cognitively intact, but her EMR only documented a few care conferences, and she stated she was not invited to quarterly care conferences. The SW said conferences were done quarterly and residents/families were informed, but no additional documentation for the resident could be found; the DON said she did not typically attend and that SW and nurse managers handled them.
A resident with arthritis, stroke, dementia, and impaired upper extremities was observed with long, uneven fingernails and contracted hands that she said were too painful to open. Staff said nail care was offered on shower days and that refusals were communicated, while the DON stated she expected weekly nail care and reapproach after refusals. The resident’s family had already raised concern about the fingernail length at care conference, but the nails remained long and untrimmed.
Failure to report elevated blood glucose readings: A resident with DM, HF, and TBI had repeated blood glucose values well above 400 while receiving daily insulin and scheduled blood sugar checks. The EMR showed only one provider update for a BG of 510, and staff interviews confirmed the resident’s elevated readings should have been reported earlier based on the standing orders and provider-notification parameters.
A resident with severe cognitive impairment, a GT, and multiple diagnoses including stroke, HTN, and diabetes received eight crushed meds via GT while on tube feeding. An RN did not perform the ordered 30 mL water flushes before and after each med or the 50 mL flush after all meds, and later confirmed the flushes were not done. Staff interviews showed awareness that flushing was required, but their stated amounts varied, and the facility policy lacked specific GT flush instructions.
A resident with heart failure, MS, and respiratory failure had an order for continuous oxygen via nasal cannula to keep O2 saturation at 90% or above, but staff found the cannula hanging off one ear and not in place in the nostrils. The resident said she was tired, unsure where she had come from, and could not reach her call light. The BOM confirmed the oxygen was not properly placed, and an LPN later adjusted it and found the resident’s O2 saturation was 86% without signs of respiratory distress.
The facility failed to monitor stored narcotics and reconcile controlled substances for discharged or discontinued medications. Large amounts of controlled and non-controlled meds for discharged or deceased residents were found in carts, medication rooms, trash bags, boxes, and an unlocked medication refrigerator, including oxycodone, lorazepam, hydromorphone, Norco, zolpidem, tramadol, Lyrica, and Belbuca. The DON stated the controlled meds should have been double locked and counted, but she was unaware they were stored in the refrigerator and had no documentation showing required counts. Repeated pharmacy audits also noted unlocked med rooms, unsecured cabinets, and discontinued or expired meds left in storage.
Failure to follow up on monthly pharmacist recommendations occurred for one resident with anxiety, depression, bipolar disorder, and schizophrenia who was receiving antipsychotic and antianxiety medications. The CP repeatedly requested an AIMS assessment, but the request had to be reissued because it was not completed; the RN manager stated the facility lacked a process for completing AIMS assessments and only did them when the CP recommended them, and the DON stated there was a problem tracking pharmacist reviews for timely follow-up.
QAPI failed to sustain compliance with repeat deficiencies involving quality of care, infection control, respiratory care, and call light access. A resident’s insulin readings outside parameters were not reported to the provider, another resident did not receive oxygen as ordered and also did not have the call light within reach, and wound care was performed without maintaining infection control measures. The facility had prior citations in these same areas, and the QAPI plan stated projects would be reviewed for sustainability after goals were met.
Failure to perform hand hygiene during wound care was observed for a resident with a stage 3 pressure ulcer, local skin infection, and EBP orders. An RN changed from soiled to clean gloves multiple times without cleaning hands first while applying wound treatment supplies and dressings. The RN stated she believed two pairs of gloves were an acceptable substitute, while the DON and other staff stated hand hygiene was required between glove changes and when entering or exiting the room.
Failure to Provide Offered Pneumococcal Vaccination: A resident with bipolar disorder, PTSD, HTN, weakness, and CKD was found eligible for a pneumococcal vaccine based on immunization history, and the resident signed consent to receive it. However, the MAR/medical record lacked evidence the vaccine was administered, and the DON confirmed it had only been offered and not provided. The facility’s policy required immunization status review on or near admission and offering the vaccine when indicated.
A resident with heart failure, MS, and respiratory failure was observed in a wheelchair with her oxygen NC out of place and her call light wrapped around the bed rail on the opposite side of the bed and out of reach. The BOM confirmed the resident could not reach the call light and left the room without moving it within reach, and an LPN later adjusted the NC and obtained an O2 saturation of 86%. The DON stated a call light should always be within reach, and no call light policy was provided.
Broken Room Storage Fixtures Not Maintained: A resident with diagnoses including borderline personality disorder, pain, anxiety, insomnia, neuropathy, and depression reported that room drawers and closet doors had been broken for a long time and that maintenance requests had not resolved the issue. Surveyors observed drawers without pull tracks that came out of the cabinet and closet doors that would not close, while work orders showed repeated requests for the same problem and the MD and administrator confirmed the concerns were known but had not been fully addressed.
A resident admitted with a fractured tibial spine and orders for PT/OT did not receive therapy evaluation in a timely manner. Family reported repeated questions about when therapy would start, and therapy staff later said they were unaware the resident had been admitted. Facility staff confirmed the delay, could not explain why it occurred, and the facility policy called for new therapy referrals to be evaluated within 24-48 hours.
The facility failed to maintain appropriate food temperatures, affecting two residents and potentially all 93 residents consuming food from the main kitchen. Observations revealed that hot food was served cold and cold food was served warm, with recorded temperatures not meeting facility policy. Interviews with staff confirmed the process for food delivery, but discrepancies in temperature standards were noted.
A long-term care facility was found deficient in infection control practices, including improper disinfection of a shared glucometer, failure to perform hand hygiene during perineal care, and inadequate hand hygiene between assisting residents during meals. These actions were contrary to the facility's policies and expectations, potentially leading to cross-contamination and the spread of infections.
A facility failed to create a comprehensive care plan for a resident with mood and behavior issues, lacking individualized interventions and specific target behaviors. Despite staff awareness of the resident's mood swings, paranoia, and refusal of care, the care plan did not provide specific strategies to manage these behaviors. The facility's policy required care plans to include both pharmacological and non-pharmacological interventions, which was not adequately implemented.
A resident with diabetes and dementia, who had a diabetic ulcer on the left heel, was not provided with Prevalon boots as required by their care plan. Observations revealed the resident lying in bed with bare feet, while the boots were left in a recliner. Interviews with staff confirmed the expectation for the boots to be worn to aid healing and prevent further skin breakdown, but this intervention was not implemented.
A facility failed to transcribe and follow oxygen orders for a resident with chronic respiratory conditions. Despite a care plan indicating continuous oxygen therapy at 3 liters per minute, the resident's physician orders lacked an oxygen order. Observations showed inconsistencies in oxygen administration, with staff unsure how the order disappeared from the chart, violating the facility's oxygen policy.
A facility failed to assess and identify target behaviors for a resident on psychotropic medication, impacting the evaluation of medication effectiveness. The resident exhibited mood swings, paranoia, and refusal of care, but the care plan lacked specific target behaviors. Staff interviews revealed inconsistent management of the resident's behaviors, and the director of nursing acknowledged the need for specific behavior documentation.
A facility failed to ensure a resident's call light was accessible, despite the resident being cognitively intact and dependent on staff for daily living activities. Observations found the call light out of reach, and staff confirmed the resident's ability to use it and the need for it to be within reach due to fall risk. The facility's policy required accessible call lights, highlighting a deficiency in adherence to this policy.
A resident with a stage 4 sacral pressure ulcer experienced a significant delay in scheduling an MRI, ordered to rule out osteomyelitis. The MRI was ordered on 9/3/24 but not scheduled until 10/2/24, with the appointment set for 10/21/24. The delay was due to insurance issues and lack of timely follow-up by facility staff. The DON acknowledged the failure to schedule the MRI promptly and the absence of a clear policy for imaging services.
A resident with cognitive impairments and identified as a fall and elopement risk was not provided with the required 15-minute safety checks and one-to-one staff care as outlined in their baseline care plan. This oversight led to the resident opening a facility fire door and falling outside. Staff interviews revealed communication gaps and a lack of awareness regarding the care plan requirements, resulting in the failure to implement necessary safety measures.
A resident with a history of substance use was not provided with the required written notification for discharge from the facility. Despite being cognitively intact, the resident was intoxicated and refused to sign the discharge notice. The administrator acknowledged the resident's impaired state during the notice issuance, and the resident later learned about the discharge from a hospital social worker, not from the facility as required by policy.
A resident was transferred to a hospital for detox without being informed of the bed hold policy, as required by regulations. The resident, who was cognitively intact and had a history of substance use, was not coherent enough to sign the agreement, and the facility did not contact the resident's representative. Interviews with staff confirmed the oversight, highlighting a deficiency in the facility's adherence to regulatory requirements.
The facility failed to ensure proper PPE use for residents under enhanced barrier and respiratory precautions. Staff did not wear gowns during high-contact care for a resident with a Foley catheter and another with a PICC line. Additionally, a resident on enhanced respiratory precautions had their door left open, contrary to guidelines. The facility cited insufficient PPE supplies and incomplete staff education as contributing factors.
A resident with multiple diagnoses requested to have his legs tied with a bed sheet to prevent falling off the bed. The facility failed to assess this as a potential restraint, lacked a physician's order, and did not update the care plan. Staff were unaware of the need for formal assessment, and the facility's policy on restraints was not followed.
Medication Labeling and Controlled Drug Storage Deficiencies
Penalty
Summary
The facility failed to ensure medications were properly labeled for 4 residents, including R48, R56, R109, and R102, during review of medication carts. On the TCU medication cart, R48 had two Lantus insulin pens without clearly marked open dates and expiration dates, and R56's bottle of prednisolone 1% solution eye drops had no open date or expiration date. The CC stated that injectable medications, eye drops, ear drops, nasal sprays, and creams must be labeled with open and expiration dates, and confirmed the items were not clearly labeled for use. During review of LTC medication cart station 3, a blue water cup contained 2 Humalog pens, 2 Lantus pens, and 1 Victoza pen, and no pharmacy labels were affixed to the pens. An LPN stated she was unsure how to perform the 3 checks and confirmed there was no pharmacy label to indicate name, dose, route, or time. Later, two square locked metal boxes were found inside the medication room refrigerator containing liquid lorazepam intensol; the DON could not locate keys and maintenance had to pry open the boxes. At LTC medication cart station 4, Lantus insulin pens for R109 and R102 also had no pharmacy labels. The DON stated all medications were required to have pharmacy labels with clear dosing instructions, and that insulin pens, eye drops, nasal sprays, and creams required open and expiration dates attached to the container.
Failure to Maintain Resident Facial Grooming
Penalty
Summary
The facility failed to ensure facial hair was trimmed for one resident who was reviewed for dignity. The resident’s quarterly MDS showed she was cognitively intact and had diagnoses including arthritis, stroke, and dementia, with impairment to both upper extremities and substantial to maximum assistance needed for personal hygiene, including shaving. During observation, she was seen with 1/4 to 1/2 inch long white hairs on her chin, and she stated that her hands were contracted and it was too painful to open them. The resident’s record showed the SW offered to have her face shaved, and the resident agreed. The SW stated she did not provide hands-on care and only noticed the long chin hair, while also stating facial hair preference should have been included in the care plan. Nursing staff stated facial hair shaving was offered during morning grooming, but they were unaware of the resident refusing shaving. The resident and her family member both stated she would have preferred to have her facial hair removed. The DON stated staff were expected to provide daily basic grooming and to offer shaving weekly, with reapproach and documentation if a resident continued to refuse. The facility policy stated care and services would be person-centered and honor each resident’s preferences.
Failure to Assess Residents Before Allowing Bedside Medication Self-Administration
Penalty
Summary
The facility failed to ensure a self-administration of medications assessment was completed before allowing residents to keep and take medications at the bedside for 2 of 2 residents observed with medications in their rooms. One resident was admitted with heart failure, chronic kidney disease stage 4, anemia, and hypertensive urgency. The resident’s medication orders included carvedilol, ergocalciferol, furosemide, omeprazole, sodium bicarbonate, pregabalin, and methocarbamol, but the order summary lacked an order for self-administration or for medications to be left at the bedside, and the medical record lacked evidence of a self-administration evaluation. During observation, a medication cup with approximately 6 unidentified pills/capsules was found on the resident’s food tray, and the RN removed the medications after the resident said staff “always leaves my meds here.” The second resident was cognitively intact and had diagnoses including stroke and Barrett’s esophagus with dysplasia. The resident had an order for biotine lozenges per package directions per request, but the order summary did not include an order for self-administration of medications. Although a self-administration evaluation dated 11/5/25 stated the resident lacked the capacity for self-administration, the resident had throat lozenges, biotine lozenges, and Halls cough drops in the room on the bedside table and tray table, and stated the provider was aware of their use and that the brother purchased them. RN-A, RN-B, and the DON confirmed the resident did not have a provider order for self-administration or a current assessment showing the resident could manage the medications.
Late Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC) was provided at least two days before the end of a Medicare-covered Part A stay for one resident whose Medicare-covered services ended. The resident’s MDS indicated the resident was cognitively intact. The resident’s NOMNC showed services would end on 1/30/26, but the resident signed and dated the form on 1/29/26, which was less than two days before the end of Medicare-covered Part A services. The resident’s EHR did not contain evidence that the NOMNC had been provided at least two days before the end of the stay. The BOM verified that the last covered day was 1/30/26 and that the resident signed the NOMNC on 1/29/26, and stated the NOMNC should have been provided three days before the last covered day. The associate administrator stated staff were expected to provide and explain the NOMNC at least 48 hours before the end of a Medicare-covered Part A stay, and the facility policy stated the NOMNC would be completed within 48 hours of being notified of the last covered day for a Medicare/Managed Care primary resident.
Failure to Complete Regular Care Conferences
Penalty
Summary
The facility failed to complete regular care conferences for 1 resident, R9, whose quarterly MDS dated [DATE] indicated she was cognitively intact and whose diagnoses included anxiety, depression, bipolar disorder, and schizophrenia. R9’s EMR showed care conferences dated 8/22/24, 2/5/25, 6/15/25, and 11/13/25, but no additional documentation was found to show that quarterly care conferences were completed beyond those dates. During interview, R9 stated she does not get invited to quarterly care conferences. The social worker stated care conferences were completed quarterly, that residents and families were informed, and that the conference would still occur if they did not attend, but she was unable to locate any additional notes for R9. The DON stated she did not typically attend care conferences, that social work set them up and nurse managers attended to review the nursing aspect of care, and that the conferences were important to discuss care and provide regular updates to the resident and family. No facility policy for care conferences was provided.
Failure to Maintain Fingernail Care for a Resident with Contractures
Penalty
Summary
The facility failed to maintain fingernails at a reasonable length for one resident who was unable to perform ADLs independently. The resident’s quarterly MDS identified cognitive intactness, diagnoses of arthritis, stroke, and dementia, and impairment to both upper extremities, with substantial to maximum assistance needed for personal hygiene. During observation, the resident was seen with contractures in both hands and stated that she could not open her hands because it was too painful. Her fingernails were observed to be long, uneven, and covered with chipping red paint. Staff interviews indicated nail care was offered on shower days, and the RN stated residents were offered nail care every shower day, with the nurse manager updated about continued refusals. The family member reported raising concern about the length of the resident’s fingernails at the most recent care conference because of the resident’s hand contractures. The DON stated she expected nail care to be completed weekly, that staff should reapproach residents who refused and document continued refusals, and confirmed the resident’s nails tended to be long and her contracted hands could not be opened. The facility’s ADL policy stated residents unable to carry out ADLs would receive necessary services to maintain grooming and personal and oral hygiene.
Failure to Report Elevated Blood Glucose Readings
Penalty
Summary
The facility failed to update the provider with insulin and blood glucose readings outside of parameters for one resident. The resident was cognitively intact and had diagnoses of heart failure, diabetes, and traumatic brain injury. The resident received insulin injections daily and had an order to check blood sugars three times a day along with Lantus SoloStar 10 units subcutaneously in the morning. The resident’s standing orders signed 1/8/26 directed staff to notify the provider with two blood glucose readings less than 70 or greater than 400 in a 24-hour time frame and/or a change in condition. The resident’s MAR showed multiple elevated blood sugar readings, including 469, 415, 513, 466, 510, 539, 542, and 481. The EMR contained a progress note showing the nurse practitioner was updated on a blood sugar reading of 510, but no additional updates were documented. During interviews, an LPN stated blood sugar orders typically include parameters for provider notification and that she would use her own judgment when no parameters were provided in the order. An RN manager stated the nurse should follow the order parameters and use standing orders when no parameters were provided, and confirmed the resident’s elevated readings should have been reported prior to the documented update. The DON stated orders should contain parameters for when to update the provider and that it was important to update the provider when readings were outside of parameters so concerns about high or low values could be addressed.
Failure to Follow GT Flush Orders During Medication Administration
Penalty
Summary
The facility failed to provide gastrostomy tube water flushes with medication administration according to physician orders for one resident. The resident had severe cognitive impairment and was dependent on staff for nutrition and hydration, medication administration, oral and personal hygiene, and mobility. The resident also had diagnoses of stroke, hypertension, diabetes, and a gastrostomy tube. Orders included multiple medications to be given via gastrostomy tube, and facility standing orders directed staff to flush the tube with 30 mL of water before and after each medication and with 50 mL of water after all medications were administered and after completion of enteral feeding. During observation, an RN administered eight crushed medications through the resident’s gastrostomy tube while the resident was receiving tube feeding. The RN mixed each medication with 20 mL of water, disconnected the feeding, and pushed each medication solution into the tube, but did not provide the ordered 30 mL flush after each medication or the 50 mL flush after all medications were given. The RN confirmed the flushes were not performed. Interviews with an LPN, an RN, and the DON showed staff understood that flushing was required between medications and after completion, but their stated flush amounts differed and the DON stated the expectation was that staff complete this step for all residents receiving medications via gastrostomy tube. The facility policy on general medication administration did not include specific instructions for gastrostomy tube flushes, and a requested tube-medication policy was not provided.
Oxygen Not Properly Applied to Resident
Penalty
Summary
The facility failed to ensure oxygen was administered as ordered for one resident who was reviewed for oxygen therapy. The resident’s quarterly MDS indicated she was cognitively intact and able to understand others and express her wants and ideas. Her diagnoses included heart failure, multiple sclerosis, and respiratory failure. Her summary report dated 2/13/26 included an order for oxygen at 2-3 LPM via nasal cannula continuously to maintain oxygen saturation at 90% or above. During observation on 2/10/26 at 9:28 a.m., the resident was in her wheelchair at the side of her bed with her feet in the footrests, and her oxygen nasal cannula was hanging off her right ear and not properly placed in her nostrils. She stated she had just returned to her room but was unsure where she had come from, that she was tired and wanted to lie down, and that she was unable to reach her call light for assistance. The BOM later confirmed the cannula was not properly placed and that the resident could not reach her call light. When the LPN entered the room, she adjusted the cannula and confirmed it had not been on correctly; she was unsure how long the resident had been without oxygen. The resident’s oxygen saturation was then checked and was 86%. The LPN confirmed the resident was not showing signs of respiratory distress, including gasping, shortness of breath, confusion, or cyanosis. The DON stated the nurse should ensure oxygen was placed correctly and check oxygen saturations if a resident was found without oxygen as ordered.
Failure to secure and destroy discontinued medications and controlled substances
Penalty
Summary
The facility failed to implement a system to monitor stored narcotics and complete controlled substance reconciliation for discontinued medications and discharged residents. During observation, approximately 25 cards containing discontinued or expired medications were found on a shelf in the Care Coordinators office in the transitional care unit, and the CC stated the cards were from residents who had discharged or had order changes and needed to be destroyed, but she did not have time to do so. The CC also stated she had been doing the work of two people after another care coordinator quit and that medication destruction was not a priority. Additional observations in the transitional care unit showed large quantities of medications for discharged or deceased residents stored in medication carts and rooms. One cart contained multiple controlled medications, including oxycodone, lorazepam, hydromorphone, Norco, zolpidem, tramadol, Fioricet, Lyrica, and Belbuca. Another medication room contained a 30-gallon clear plastic bag full of non-controlled medication cards for discharged or deceased residents. A later observation found two 40- to 45-gallon trash bags and two overflowing boxes of non-controlled medication cards for discharged or deceased residents, along with two metal boxes in an unlocked medication refrigerator containing liquid lorazepam bottles. Facility and pharmacy review documents showed repeated findings of unlocked medication rooms, unsecured cabinets, discontinued or expired medications not removed, and lock boxes in refrigerators that were locked but not secured. The DON stated the metal boxes in the refrigerator contained controlled medications that were supposed to be double locked and counted, but she was unaware they were there and could not locate documentation showing they had been counted. She also stated she had been slowly trying to complete destruction of medications from discharged or deceased residents since being hired and that narcotics were to be destroyed by unit managers or care coordinators. The facility policy on disposal of medications lacked a specific timeline for destruction of discontinued or discharged resident medications.
Failure to Follow Up on Pharmacist Recommendations
Penalty
Summary
The facility failed to follow up on pharmacist recommendations for 1 of 5 residents reviewed for monthly pharmacist reviews. The resident had a quarterly MDS showing cognitive intactness and diagnoses of anxiety, depression, bipolar disorder, and schizophrenia, with use of antipsychotic and antianxiety medications. The consultant pharmacist documented repeated recommendations in the EMR on 9/8/25, 10/13/25, 11/9/25, 12/7/25, 1/12/26, and 2/8/26, including a recommendation to complete an AIMS assessment that had been reissued from November 2025. The resident’s EMR showed the AIMS assessment was not completed until 2/10/26. During interview, the consultant pharmacist stated he reviewed residents monthly for needed monitoring, medication interactions, and gradual dose reductions, and confirmed he had to reissue AIMS requests because they were not being completed. The RN manager stated she received monthly pharmacist reviews, had received some requests to complete AIMS assessments, and had not kept up with them. She also stated the facility did not have a process for completing the AIMS assessment and only completed it when recommended by the consultant pharmacist. The DON stated the monthly pharmacist reviews were passed to nurse managers or the provider for follow-up and that there had been a problem tracking the reviews to ensure they were addressed timely.
QAPI Failed to Sustain Compliance With Repeat Quality, Infection Control, Respiratory Care, and Call Light Deficiencies
Penalty
Summary
The facility failed to ensure its QAPI committee effectively sustained ongoing compliance related to repeat citations from prior surveys involving quality of care, infection control, respiratory care, and the resident call system. Review of the CASPER report updated 1/14/26 showed the facility had previously been cited at F684 for quality of care on the surveys exited 11/2/23 and 1/9/25, at F695 on the survey exited 1/9/25, at F880 for infection prevention and control on the surveys exited 11/2/23 and 1/9/25, and at F919 on the surveys exited 11/2/23 and 1/9/25. These same areas were identified again during the current survey. The report states that for R101, the facility failed to update the provider with insulin readings outside of parameters. For R38, the facility failed to ensure oxygen orders were administered as ordered and also failed to ensure the call light was within reach. For R61, the facility failed to maintain infection control measures during wound care. On 2/13/26, the associate administrator stated prior citations had been addressed through the facility plan of correction with audits, and that once QAPI determined compliance based on audit results, the audits were decreased or suspended, although QAPI continued to discuss the concerns. The facility's QAPI plan, reviewed 9/25/25, stated that once a PIP project met its goals, it would be reviewed at the following quarterly QAPI meeting to ensure sustainability.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain infection control measures during wound care for a resident with an intact cognition, a stage 3 pressure ulcer of the left buttock, local infection of the skin and subcutaneous tissue, and morbid obesity. The resident’s care plan indicated the resident was on Enhanced Barrier Precautions related to the wound and required staff to follow PPE procedures during high-contact care. The resident’s wound orders included cleansing the buttocks wound, applying skin prep, collagen, and a hydrocolloid dressing, and following EBP while providing wound care and other high-contact care activities. During observation, an RN provided wound care while wearing PPE, but after removing soiled gloves she did not perform hand hygiene before putting on clean gloves. This occurred more than once during the wound care process, including after cleansing and drying the wound and again before applying collagen powder, calcium alginate, and the hydrocolloid dressing. The RN later stated she believed wearing two pairs of gloves was an acceptable alternative to hand hygiene between glove changes. Other staff interviewed stated hand hygiene should be performed when entering the room, between dirty and clean glove changes, and when exiting the room, and the DON stated wearing two pairs of gloves was not a safe alternative to hand hygiene.
Failure to Provide Offered Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that 1 of 5 residents reviewed for immunizations, R11, was offered, educated about, and/or provided the pneumococcal vaccination series as recommended by the CDC. R11’s face sheet identified the resident as [AGE] years old, admitted on [DATE], with diagnoses including bipolar disorder, post-traumatic stress disorder, weakness, hypertension, and chronic kidney disease. The CDC Adult Immunization Schedule dated 08/07/2025 identified that adults who had not received the complete pneumococcal series, or whose history was unknown, may receive PCV20, PCV-15, or PCV-21. R11’s MIIC report showed a pneumococcal vaccination on 4/3/2015, but did not identify which vaccine was given, making R11 eligible for a pneumococcal vaccination. R11 signed a vaccine administration consent form on 10/6/2025 consenting to receive a pneumococcal vaccination, but the medical record lacked evidence that the vaccine was administered. On 2/13/26 at 1:47 p.m., the DON stated the facility had offered R11 a vaccination approximately one month earlier, but it had not been provided. The DON stated the expectation was that vaccination eligibility would be evaluated upon admission and the vaccine provided after the resident’s status was verified, and confirmed that R11’s vaccination had not been administered. The facility’s Pneumococcal Policy, last revised 2/2024, stated residents would be assessed for current immunization status and eligibility prior to or upon admission within 5 days, and offered the vaccine within 30 days of admission when indicated.
Call Light Not Within Reach for Resident
Penalty
Summary
A resident with diagnoses including heart failure, multiple sclerosis, and respiratory failure was observed in a wheelchair at the side of her bed with her feet in the footrests, leaning to the right, and with her oxygen nasal cannula out of her nostrils. The resident stated she was tired and wanted to lie down, and she pointed to the opposite side of the bed when asked about her call light. The call light cord was wrapped around the bed rail on the opposite side of the bed and was out of reach. The resident’s quarterly MDS indicated she was cognitively intact and able to understand others and express her wants and needs. The business office manager entered the room and confirmed the resident’s oxygen nasal cannula was not in place and that the call light was out of reach, but left the room without moving the call light within reach. Later, an LPN adjusted the nasal cannula and obtained an oxygen saturation reading of 86%, and stated she was unsure how long the oxygen had not been properly in place. During interview, the BOM confirmed she had left the room without ensuring the call light was within reach, and the DON stated a call light should always be within reach and that every employee should watch to ensure it is within reach. No call light policy was provided.
Broken Room Storage Fixtures Not Maintained
Penalty
Summary
The facility failed to ensure resident rooms were kept in good working condition for one resident whose room drawers and closet were broken. The resident had diagnoses including borderline personality disorder, pain, anxiety, insomnia, neuropathy, and depression. During screening, the resident stated the drawers and closet had been broken for a long time, that they had reported the concern to the social worker and filed maintenance reports, and that the items were still broken. The resident also stated maintenance had tried to fix the issue but could not, and replacement was needed. Observation of the room showed the drawers lacked pull tracks and would come out of the cabinet with very little effort, with all drawers sharing the same condition. The closet doors did not close, and the resident said they could not store belongings except for very lightweight items in the drawers and had to keep belongings in bags and boxes throughout the room. Facility work orders dated September, October, and November 2025 documented repeated maintenance requests for the room, including drawers coming off, hooks for hanging, drawers and cabinets needing to be addressed, and drawers being unusable and off track. The maintenance director confirmed awareness of the broken drawers and closet and stated they were due to be replaced in a remodel, but the work had not been completed. The administrator also confirmed awareness of the concerns since September 2025 and stated broken drawers or cabinets should be addressed right away.
Delayed PT/OT Evaluation After Admission
Penalty
Summary
The facility failed to provide physician-ordered PT and OT services in a timely manner for one resident who was admitted with diagnoses including hypertension, hyperlipidemia, and a displaced fracture of the left tibial spine. The resident’s hospital discharge paperwork dated 12/22/25 included an order for referral to PT and OT services and noted the resident would likely need a TCU stay with PT/OT post-op. The resident’s care plan identified altered mobility and fall risk, with interventions to follow PT and OT instructions, and the care plan was initiated on 12/29/25. The resident’s family member stated the resident was not evaluated by PT/OT until 12/29/25 and that staff did not give a clear answer when asked when therapy would start. The family member reported being told the facility was switching therapy companies and later being told by therapy staff that they were unaware the resident had been admitted and were waiting for therapy services. OT and PT evaluation notes dated 12/29/25 documented the resident’s impairments and need for skilled therapy, and the PT evaluation indicated therapy was to occur 3 times per week for 32 days. Facility staff confirmed the resident was admitted but not seen by therapy until 12/29/25, stated they were unsure why there was a 7-day delay, and noted there were no charted reasons for the delay. The facility policy stated new referrals should be evaluated within 24-48 hours and plans communicated with nursing staff and residents/family.
Deficiency in Food Temperature Maintenance
Penalty
Summary
The facility failed to ensure that food was served at a palatable and appetizing temperature for two residents, which had the potential to affect all 93 residents consuming food from the facility's main kitchen. The deficiency was identified through observations, interviews, and document reviews. Two residents, both with intact cognition, reported that hot food was served cold and cold food was served warm. During an observation, a test tray was requested, and the temperatures of the food items were recorded. The cold roast beef sandwich was found to be 158 degrees Fahrenheit, while the mashed potatoes, gravy, and pureed corn were 115, 129, and 113 degrees Fahrenheit, respectively. These temperatures did not meet the facility's policy requirements for food temperatures. Interviews with the dietary aide and culinary director revealed that the process involved plating the food, covering it, and placing it on a tray for delivery to residents' rooms. The dietary aide and culinary director both stated that hot food should be held at a minimum of 135 degrees Fahrenheit, and cold food should be served no warmer than 41 degrees Fahrenheit. However, the facility's policy indicated that cold food should be at or below 50 degrees Fahrenheit and hot food at or above 140 degrees Fahrenheit. The discrepancy between the observed food temperatures and the facility's policy highlights the deficiency in maintaining appropriate food temperatures for residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices, as evidenced by multiple deficiencies observed during a survey. One significant issue involved the improper disinfection of a shared glucometer after use on a resident with diabetes mellitus. The LPN responsible for checking the resident's blood sugar did not disinfect the glucometer before placing it back in a bin with clean supplies, citing being rushed as the reason for the oversight. This practice was contrary to the facility's expectations and policies, which required disinfection to prevent the spread of bloodborne pathogens. Another deficiency was observed during perineal care for two residents. Nursing assistants failed to perform hand hygiene after removing soiled gloves and before donning clean gloves while assisting residents with incontinence care. This included tasks such as tucking in clean linens and adjusting incontinence products without changing gloves or washing hands, leading to potential cross-contamination. Interviews with staff and clinical managers confirmed that the expected protocol was not followed, which required hand hygiene between dirty and clean tasks. Additionally, the facility did not ensure hand hygiene was performed by staff between assisting multiple residents during meal service in the dining area. An LPN assisted several residents with eating without washing hands between residents, despite handling utensils and wiping residents' mouths. The facility's policy required hand hygiene to prevent cross-contamination, but the LPN did not adhere to these guidelines, believing it was unnecessary since they did not touch the food directly. Interviews with clinical managers and the DON highlighted the expectation for staff to perform hand hygiene between assisting different residents to maintain sanitary practices.
Failure to Develop Comprehensive Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident (R32) with mood and behavior issues. R32's care plan lacked individualized interventions and specific target behaviors to monitor the effectiveness of interventions. Despite being cognitively intact and having no documented behaviors or rejection of care upon admission, R32 exhibited mood swings, paranoia, and refusal of care, including eating and taking medications. The care plan directed staff to document mood states and behaviors as they occurred and to provide emotional support and comfort measures as needed. However, it did not include specific strategies tailored to R32's needs or behaviors. Interviews with staff revealed a lack of awareness and specific strategies to manage R32's behaviors. Nursing assistants and LPNs reported R32's behaviors, such as hallucinations and refusal of meals, but were not provided with specific interventions to address these issues. The social worker was not informed of R32's recent refusals and behaviors, and the clinical managers noted that target behaviors were entered into the medication or treatment administration record but did not align with the care plan. The facility's policy required care plans to reflect both pharmacological and individualized non-pharmacological interventions, along with monitoring for efficacy, which was not adequately implemented for R32.
Failure to Apply Prevalon Boots for Resident with Diabetic Ulcer
Penalty
Summary
The facility failed to ensure that Prevalon boots were applied to both feet of a resident, identified as R44, who was reviewed for non-pressure skin conditions. R44, who was cognitively impaired and diagnosed with diabetes mellitus and dementia, had a diabetic ulcer on the left heel. The care plan, revised on 12/10/24, required Prevalon boots to be worn on both heels while the resident was in bed. However, during multiple observations on 1/6/25 and 1/7/25, R44 was found lying in bed with bare feet resting directly on the mattress, and the boots were observed lying in a recliner across the room. Interviews with nursing staff, including a nursing assistant, nurse manager, nurse practitioner, and the director of nursing, confirmed that the expectation was for R44 to have the boots on while in bed to aid in healing the current wound and prevent further skin breakdown. The facility's policy on skin assessment and wound management, revised in 7/18, indicated that staff should update care plans and implement interventions when a significant alteration in skin is noted. Despite these guidelines, the necessary intervention of applying Prevalon boots was not followed, leading to the deficiency.
Failure to Transcribe and Follow Oxygen Orders
Penalty
Summary
The facility failed to transcribe and follow an oxygen order for a resident, identified as R17, who was reviewed for oxygen use. R17 had intact cognition and required assistance with activities of daily living due to conditions such as heart failure, asthma, and chronic respiratory failure. Despite having a care plan that included continuous oxygen therapy at 3 liters per minute via nasal cannula, R17's physician orders lacked an order for oxygen use. The discharge orders from a previous hospital stay indicated the need for continuous oxygen at 3 liters, but this was not reflected in the facility's records. Observations and interviews revealed inconsistencies in the administration of oxygen to R17. On one occasion, R17 was observed receiving oxygen at 3 liters per minute, while on another, the oxygen was set at 2.5 liters per minute, contrary to the care plan and discharge orders. Staff members, including LPNs and the Director of Nursing, were unsure how the oxygen order disappeared from the chart, and the facility's oxygen policy required a physician order for oxygen management. This deficiency highlights a failure in maintaining accurate and consistent medical orders for oxygen therapy, which is crucial for the resident's respiratory care.
Failure to Assess and Monitor Psychotropic Medication Effectiveness
Penalty
Summary
The facility failed to comprehensively assess and identify target behaviors to determine the effectiveness of psychotropic medication for a resident reviewed for mood and/or behavior. The resident, who was cognitively intact and required assistance with certain activities, was noted to have an alteration in mood and behavior. The care plan directed staff to document mood states and behaviors, provide emotional support, and conduct assessments as needed. However, the care plan did not identify specific target behaviors to be monitored, which is crucial for evaluating the effectiveness of psychotropic medications. The resident's physician orders included targeted behaviors such as dry mouth, agitation, headaches, and abnormal involuntary movements, with directions to chart non-pharmacological interventions and their outcomes. Despite these orders, the medication administration record showed the resident was prescribed Haloperidol for agitation, but there was no comprehensive assessment of the target behaviors. Progress notes indicated multiple instances of the resident refusing care, treatments, and medications, as well as displaying behaviors such as throwing drinks and food on the floor. Interviews with staff revealed a lack of awareness and specific strategies to address the resident's behaviors. Nursing assistants and LPNs described the resident's mood swings, paranoia, and refusal of meals and medications, but there was no consistent approach to managing these behaviors. The social worker was not aware of the resident's recent refusals and behaviors, and clinical managers stated they monitored target behaviors based on medication side effects rather than specific behavioral changes. The director of nursing acknowledged that the target behaviors listed were medication side effects and agreed that specific behaviors like delusions or hallucinations should be documented to monitor the effectiveness of psychotropic medications.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was accessible for a resident who was reviewed for call light accessibility. The resident, who was cognitively intact and had diagnoses of anxiety and depression, was dependent on staff for activities of daily living and mobility. The resident's care plan included an intervention to ensure the call light was within reach and answered promptly, as this helped reassure the resident. However, during observations, the call light was found on the floor under the bed and attached to the bed rail, both times out of the resident's reach. The resident expressed that the call light was often left out of reach, and staff confirmed that the resident was able to use the call light and was a fall risk, necessitating the call light to be within reach. Interviews with staff, including a nursing assistant, nurse manager, and director of nursing, verified that the call light was not within reach of the resident, despite the expectation that it should be. The facility's policy required that residents have a means of directly contacting caregivers when in their rooms, and the system should be functioning properly. The failure to ensure the call light was accessible to the resident represents a deficiency in the facility's adherence to its policy and the care plan for the resident.
Delayed MRI Scheduling for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to ensure timely follow-up on ordered radiologic studies for a resident with a stage 4 sacral pressure ulcer, which included exposed bone. The nurse practitioner (NP) ordered an MRI on 9/3/24 to rule out osteomyelitis, a bone infection, due to the severity of the wound. Despite the urgency, the MRI was not scheduled until 10/2/24, with the appointment set for 10/21/24. The delay in scheduling the MRI was attributed to issues with the resident's insurance and a lack of timely follow-up by the facility staff. The health information assistant (HIA) was responsible for scheduling the MRI but did not become aware of the order until 9/26/24, nearly three weeks after it was placed. The HIA cited difficulties with the resident's insurance as a reason for the delay. The nurse practitioner expressed concern over the prolonged scheduling process, noting that attempts to schedule the MRI should have been made within two weeks of the order. The director of nursing (DON) confirmed that the MRI was not scheduled in a timely manner and acknowledged that the facility lacked a clear policy for imaging and diagnostic services. The DON stated that the MRI should have been scheduled by early September, shortly after the order was placed. The facility's failure to ensure timely scheduling of the MRI did not meet the expectations for executing physician orders promptly, as outlined in their policy.
Failure to Implement Baseline Care Plan for Resident
Penalty
Summary
The facility failed to implement the baseline care plan for a resident who was admitted with cognitive concerns and was identified as a fall and elopement risk. The resident's care plan required 15-minute safety checks and one-to-one staff care, which were not implemented. As a result, the resident, who was severely cognitively impaired with a BIMS score of 5 and diagnosed with encephalopathy and aphasia, managed to open a facility fire door while seated in a wheelchair and fell outside onto the concrete. This incident occurred because the safety measures outlined in the care plan were not followed. Interviews with staff revealed a lack of communication and implementation of the care plan. The registered nurse who admitted the resident reported the elopement and fall risk to the nurse manager, but the nurse manager did not recall this information. The nursing assistants were not aware of the 15-minute safety checks or one-to-one care requirements, as these were not reflected in their daily assignment sheets. The director of nursing confirmed that no safety checks were documented, and the interventions on the care plan were autogenerated and not intended to be implemented until the comprehensive care plan was completed.
Failure to Provide Written Notification for Resident Discharge
Penalty
Summary
The facility failed to provide the required written notifications for transfers to a resident and/or their representative, as evidenced by the case of a resident who was cognitively intact and had a history of substance use. The resident was independent in activities of daily living and had diagnoses including seizures, anxiety, and depression. On multiple occasions, the resident returned to the facility visibly intoxicated, which led to interactions with staff regarding their alcohol use and subsequent decisions about their care. On one particular day, the resident returned to the facility intoxicated, and staff noted the smell of alcohol and the resident's difficulty in focusing. The resident was issued a 30-day notice of discharge due to no longer requiring skilled nursing facility care, but refused to sign the notice. The administrator explained the appeal process and provided the resident with a copy of the notice, which was also mailed to the ombudsman office. However, the resident's medical record lacked documentation that the resident or their representative received a written notification of discharge. The administrator later acknowledged that the resident was very impaired when the discharge was discussed and given, and admitted that the resident might not have understood the discharge notice. The resident confirmed that they were not given a 30-day written notice before being sent to the emergency room for detoxification. Instead, the resident learned about the discharge from a social worker at the hospital. The facility's policy required written notification in a language and format understood by the resident or their representative at least 30 days prior to a facility-initiated discharge, which was not adhered to in this case.
Failure to Inform Resident of Bed Hold Policy During Hospital Transfer
Penalty
Summary
The facility failed to inform a resident or their representative about the bed hold policy during a hospital transfer, which is a requirement under 42 CFR S483.15(c)(4)(ii)(D). The resident, who was cognitively intact and had a history of substance use, was sent to the hospital for detox after appearing intoxicated upon returning from a leave of absence. The facility's progress notes indicated that the resident was not coherent enough to sign a bed hold agreement, and the facility did not reach out to the resident's family or legal representative to provide the necessary information. Interviews with the facility's administrator and director of nursing revealed that the bed hold policy was not communicated due to the resident's impaired state. The facility's policy requires that a notice of transfer and bed hold information be provided to the resident or their representative as soon as practicable before a transfer. However, the resident reported not being aware of the bed hold policy and did not receive any form to sign. The facility's failure to provide this information constitutes a deficiency in adhering to regulatory requirements.
Inadequate PPE Use and Precaution Implementation
Penalty
Summary
The facility failed to ensure appropriate donning and doffing of personal protective equipment (PPE) for residents under enhanced barrier precautions (EBP) and enhanced respiratory precautions. For Resident 3, who had a Foley catheter and required extensive assistance with activities of daily living, staff were observed not wearing gowns while performing high-contact care activities such as dressing and transferring. Nursing assistants involved in the care of Resident 3 were unaware that gowns were required, indicating a lack of proper training or communication regarding PPE protocols. Resident 26, who had a peripherally inserted central catheter (PICC) and a wound vacuum-assisted closure device, also did not receive care with the appropriate PPE. A registered nurse was observed administering intravenous medication without wearing a gown, contrary to the expectations for EBP. The resident confirmed that not all staff adhered to the gown and glove requirements during care, highlighting inconsistencies in the implementation of infection control measures. For Resident 31, who was on enhanced respiratory precautions due to pneumonia, the facility failed to keep the resident's door closed as required. Observations noted the door was open on multiple occasions, and the infection preventionist confirmed that the facility had not fully implemented the plan for enhanced respiratory precautions. The facility's infection preventionist and director of nursing acknowledged the lack of PPE supplies and incomplete staff education as contributing factors to these deficiencies.
Failure to Assess and Document Use of Restraint
Penalty
Summary
The facility failed to comprehensively assess the use of a restrictive device, specifically a bed sheet tied around a resident's legs, as a potential restraint. The resident, who had intact cognition and multiple diagnoses including hypertension, heart failure, and anxiety disorder, required substantial assistance for activities of daily living. Despite the resident's request to have his legs tied to prevent falling off the bed, there was no evidence of a restraint assessment, physician's order, or updated care plan to justify the use of the bed sheet as a restraint. Observations confirmed that the resident was unable to move his legs out of the knotted sheet, indicating it functioned as a restraint. Interviews with staff revealed that the resident directed his own care and requested the use of the bed sheet to secure his legs. However, staff members, including a registered nurse, a nurse aide, and a licensed practical nurse, were unaware of the need for a formal assessment or physician's order for this intervention. The assistant director of nursing and the director of nursing were also not informed of the practice, and no assessments or recommendations were completed prior to implementing the restraint. The facility's policy on residents' rights emphasized the need for the least restrictive alternatives and ongoing re-evaluation of restraints, which was not adhered to in this case.
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What surveyors actually found near you
We read the 1,034 citations issued within 25 miles in the last 12 months — including the 33 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 Villas At The Cedars | 0.7 mi | ★★★★★ | 15 | 1 |
| The Estates At St Louis Park Llc | 1.2 mi | ★★★★★ | 0 | 0 |
| The Villas At Brookview | 1.6 mi | ★★★★★ | 26 | 1 |
| The Villas At The Park | 1.8 mi | ★★★★★ | 11 | 0 |
| Sholom Home West | 1.8 mi | ★★★★★ | 7 | 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.