Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Villas At St Paul during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, severely impaired cognition, a history of wandering, and use of a walker exited the facility without staff awareness and was later found miles away at her previous home. Records showed her wander guard and 15-minute safety checks had been discontinued before the event, despite prior elopement risk documentation and past wandering behaviors. Staff searched after she was seen outside, but she had already traveled through a busy area and was missing for about 2.5 hours.
Failure to report resident elopement to SA: A resident with severely impaired cognition, Alzheimer’s disease, and recent hip fracture repair was seen outside the building, searched for by staff, and later found at a neighbor’s house after hitch-hiking to a previous address. RN notified police, the DON, and the administrator, but the incident was not reported to the SA because leadership did not consider it an elopement.
The facility failed to code the MDS accurately for two residents. One resident’s MDS listed tube feeding in section K even though the chart, nutrition assessments, care plan, and observation did not support tube feeding, and the MDS coordinator said it should have reflected IV fluids instead. Another resident’s MDS did not accurately capture medication refusal, even though the MAR showed furosemide was refused 5 of 7 days in the lookback period and progress notes documented the MD was notified of intermittent refusal.
Incomplete Care Plan for Repeated Diuretic Refusals: A resident with dementia, HTN, and failure to thrive repeatedly refused a daily diuretic ordered for edema, but the care plan did not include goals, desired outcomes, or interventions related to the refusals. The resident's Risk vs Benefits form was not incorporated into the plan, and staff described only general discussions about medication refusal rather than specific diuretic side effects or alternatives. During the survey, the resident was observed with painful bilateral lower-leg edema and said no one had discussed alternatives with him.
A resident’s care plan was not revised to match changing needs. The resident had Alzheimer’s disease, wounds, and a history of C-diff, but the care plan and TAR still reflected contact precautions and C-diff treatment after the infection had resolved, and the plan did not include the ordered Prevlon boot intervention for altered skin integrity. Staff and the DON acknowledged the resident should have been on EBP for wounds and that the orders and care plan should have been updated to reflect the current status.
A resident with Alzheimer’s disease, diabetes, PVD, incontinence, and stage 4 coccyx and unstageable ankle pressure ulcers did not have ordered skin integrity interventions consistently in place. The care plan lacked the ordered Prevlon boot intervention, staff observed the resident without boots or heel offloading, and the air mattress repeatedly showed a low-pressure indicator while multiple staff entered the room without addressing the malfunction. Staff also gave inconsistent accounts about the boots, and the resident stated she did not have them overnight.
A resident with DM, ESRD, dialysis, and a therapeutic diet was at risk for weight loss, dehydration, and nutritional problems, but supplement intake was not accurately documented. Although the TAR showed full consumption of Ensure Clear, observation found multiple unopened bottles stored in the resident’s room, and the resident stated he did not drink all of the supplement because of concern about blood glucose. The RD relied on EMR intake records for assessment and said she was unaware of the resident’s reluctance to take the supplement.
A resident with ESRD and diabetes received dialysis, but staff failed to monitor the dialysis access correctly after the resident’s access changed from a CVC in the right chest to an AV fistula in the left upper arm. Nursing staff documented checks for bleeding and post-dialysis status, but were not aware of the fistula, did not assess for bruit and thrill, and did not have direction to avoid BP checks on the access arm. The DON stated staff should know the correct access site and assess it based on the type and location of access.
The facility failed to keep medical records accurate for two residents. One resident with diabetes, ESRD, and a therapeutic diet had documentation showing full daily Ensure intake even though unopened Ensure bottles were found in the room and the resident said he did not drink all of them. Another resident with Alzheimer’s disease, C-diff history, and wounds still had contact precautions documented and signed off in the TAR even after the record stated C-diff had resolved and EBP was in place.
Failure to Offer Updated Pneumococcal Vaccination: The facility failed to ensure two residents were offered and/or provided updated pneumococcal vaccination per CDC guidance. One resident over age 65 with DM2, kidney failure, and DVT had records showing prior PCV13 and PPSV23 but no evidence of PCV20 or PCV21, and the chart stated the vaccine was not indicated and the resident was up to date. Another resident, younger than 65 with CAD, thyroid disease, and malnutrition, also had PPSV23 documented with no evidence of PCV20 or PCV21, while the consent form likewise stated the vaccine was not indicated and the resident was up to date.
A resident with multiple serious medical conditions and intact cognition received PRN Oxycodone on several occasions without documentation of the specific pain indication, symptoms, or non-pharmacologic interventions attempted prior to administration. Although the care plan and facility staff (including an LPN, RN, NP, and DON) described an expected process of assessing pain using a 0–10 scale, identifying pain location and characteristics, offering measures such as repositioning, ice, heat, food, or distraction, and then documenting the PRN narcotic administration and its effectiveness, the MAR and progress notes lacked this required information. The facility’s own Medication Administration policy requiring documentation of complaints or symptoms, date and time, dose, route, and results of PRN medications was not followed for these Oxycodone doses.
A resident with multiple chronic conditions had provider orders for daily cranberry capsules for UTI prophylaxis and daily lactobacillus for diarrhea, but the facility failed to administer numerous doses over an extended period. MARs showed repeated missed doses of both medications, with nursing notes documenting that the medications were on order, not available, or awaiting pharmacy or house stock delivery. An LPN described the process for documenting unavailable medications and contacting the pharmacy, and the DON described the house stock request process and defined missed doses as medication errors. The NP reported she was not notified about the missed doses, despite expecting to be contacted when medications were not administered as ordered.
A resident with hypomagnesemia and multiple serious diagnoses had an order for oral magnesium 250 mg daily that was not administered for five consecutive days, with MAR entries coded as unavailable and nursing notes stating the medication was on order or awaiting pharmacy delivery. Magnesium was an OTC item stocked in the facility, but the correct strength was not requested via house stock procedures, and the provider was not notified of the missed doses. During this time, labs showed persistently low magnesium, and documentation noted fatigue, lethargy, nausea, poor intake, and leg pain. An NP later documented that the resident’s magnesium supplement had not been started due to tablet strength issues, the pharmacy reported no request for the ordered dose, and the DON learned of the omissions only on later chart review. The Pharm-D characterized the five missed doses, in the context of the resident’s symptoms and lab values, as a significant medication error.
Surveyors identified deficiencies in food storage and labeling, with multiple undated and expired food items found in both kitchen and resident refrigerators, improper storage of chemical buckets near food, and ice packs stored with food. Staff interviews revealed confusion over responsibility for monitoring and discarding expired items, and dishwashing procedures were inadequate, with blank temperature logs and staff lacking training on required sanitization temperatures.
A resident with latent TB was not tracked on the infection line listing despite being prescribed antibiotics, and two residents on contact isolation for MRSA did not have consistent enforcement of transmission-based precautions. Staff entered the room without required PPE, and there was confusion among staff about when PPE was necessary, despite clear signage and care plan instructions.
A resident with cognitive impairment and multiple diagnoses was observed wearing TED stockings incorrectly, with the stockings rolled down and causing skin indentations and redness. Although the resident preferred to apply the stockings independently, nursing staff acknowledged their responsibility to ensure proper application, which was not documented in the care plan. Facility policy on TED stocking use was not provided when requested.
Several residents with cognitive and physical impairments did not receive necessary assistance with oral hygiene, as required by their care plans. Observations showed unopened or missing oral care supplies, and residents reported not being helped with oral care. Staff interviews revealed confusion about oral care procedures and inconsistent provision of services, despite facility policy requiring support for activities of daily living.
Several residents, including those with cognitive and physical impairments, did not have water or other fluids readily available outside of meal and medication times. Observations and interviews showed that residents often lacked access to drinks in their rooms and sometimes relied on staff or visitors to obtain water, despite care plans and facility policy requiring regular hydration support.
Staff with facial hair prepared food without wearing beard nets due to a supply shortage, despite knowing the requirement and facility policy mandating beard restraints to prevent hair contamination. The issue was observed and confirmed by staff interviews, and the administrator noted that the supply issue should have been communicated.
A nursing assistant delayed responding to a resident's call light and instructed the resident to use it only for emergencies, resulting in the resident's needs not being addressed promptly. Other staff were unaware of this practice, which was inconsistent with facility policy and expectations regarding timely response to resident requests.
A facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their medical and personal needs. One resident's care plan lacked focus on incontinence and dental care, another's was incomplete regarding fall risk and pain management, and the third's did not address skin integrity or communication needs. Staff interviews highlighted a lack of detailed and updated care plans, increasing the risk of neglect.
A resident developed an avoidable stage II pressure ulcer due to the facility's failure to reassess pressure ulcer risk and update the care plan. Despite being at moderate risk, the resident's care plan lacked specific interventions for pressure ulcer prevention. Staff interviews revealed a lack of awareness and documentation regarding the resident's condition and necessary interventions. The facility's policy required a pressure ulcer risk assessment and preventative measures, which were not adequately implemented.
The facility failed to verify the nurse aide registration for an agency nursing assistant before allowing him to work with residents. The staffing coordinator was unable to confirm the registration due to a last-minute shift request and reliance on an agency portal system. The director of human resources and the administrator expected the staffing coordinator to handle agency paperwork, but the confirmation of the aide's registration was received only after he had already worked with residents.
A resident with a fungal skin infection did not receive prescribed Nystatin powder due to a transcription error, leading to a lack of treatment for several days. The medication order was not confirmed and revised until days later, resulting in the resident's condition deteriorating. Staff interviews revealed a lack of awareness and communication regarding the missed applications, and facility policies were not followed.
A resident reported that staff placed a pillow over her roommate's mouth to silence her during morning care. Despite being informed, an LPN and a nursing assistant did not report the allegations to management. The resident allegedly abused denied the incident when questioned. The Director of Nursing was unaware of the allegations until informed by the surveyor, and the facility did not provide a policy on abuse reporting.
A resident with intact cognition and specific bathing preferences did not receive showers as per their preference, leading to neglect in personal hygiene. The facility failed to assess and document the resident's preferences in the MDS, resulting in inconsistent bathing schedules and lack of proper care. Staff interviews revealed confusion and inconsistency in following the bath schedule, and the facility lacked a policy on preferences.
Two residents were not provided adequate privacy during personal care due to malfunctioning privacy curtains. Despite the doors being shut, the curtains were not pulled, leaving the residents exposed when staff entered the rooms. The nursing assistant acknowledged the issue and had requested repairs, but they were not completed. The DON confirmed the expectation for privacy, but the facility's privacy policy was not provided.
A resident dependent on staff for daily living and receiving nutrition via a feeding tube had dried enteral feeding liquid on the support legs of their tube feeding pump pole. Despite multiple observations over several days, the substance remained uncleaned. Nursing staff acknowledged their responsibility to clean the equipment, but the facility lacked a specific cleaning policy for tube feeding pump poles.
A facility failed to complete a comprehensive assessment and implement a resident's preferences for bathing. The resident, who had intact cognition and required assistance for bathing, did not receive showers as preferred and had inconsistent documentation of bathing schedules. Staff interviews revealed that the MDS section for preferences was not consistently completed, and the resident's care plan lacked specific information on bathing preferences.
A resident with mobility issues and a prosthetic leg was not provided with the restorative nursing program (RNP) as planned after discharge from physical therapy. Despite the care plan's directive for daily ambulation assistance, the resident reported not using the prosthetic due to pain and had not walked for weeks. Staff interviews revealed inconsistencies in the RNP's implementation, with some staff unaware of the resident's ambulation status and others noting refusal to wear the prosthetic. The facility lacked a formal RNP policy.
A resident with severe cognitive impairment and a history of falls did not receive consistent fall prevention interventions, such as a floor mat, as outlined in their care plan. Despite being at high risk for falls, the facility failed to maintain necessary safety measures, leading to multiple falls. Observations and staff interviews revealed a lack of adherence to the care plan and inadequate communication, contributing to the deficiency in providing a safe environment.
A facility failed to monitor and assess a resident's respiratory status, leading to improper oxygen use and lack of medication administration. The resident, with COPD and impaired cognition, had no documented interventions for oxygen use in their care plan. Observations showed the resident's nasal cannula was often misplaced, and no respiratory assessments were conducted. Staff interviews revealed confusion about oxygen orders and the use of PRN inhalers, with no specific guidelines provided for respiratory assessments.
A resident with a history of stroke and diabetes, dependent on tube feeding, did not receive care in accordance with enhanced barrier precautions (EBP). An LPN was observed performing tube feeding care without wearing a gown, despite EBP signage and facility policy requiring PPE for high contact care. The LPN was misinformed about the necessity of EBP, contrary to the facility's policy and the director of nursing's guidance.
A resident with multiple pressure ulcers did not have wound care orders properly documented in the EMR, leading to a lack of continuity in care. Despite having a care plan, it lacked specific directions for dressing changes. Observations showed that dressing changes were not documented, and the director of nursing confirmed the absence of orders in the EMR, indicating a breakdown in communication and documentation processes.
Failure to Supervise Resident With Cognitive Impairment Led to Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for one resident who was reviewed for elopement. The resident had severely impaired cognition, a diagnosis of Alzheimer’s disease, and a history of hip fracture repair. She was ambulatory with a walker and had documented wandering and exit-seeking behaviors in prior nursing notes, including walking the halls at night, attempting to get on the elevator repeatedly, and being found wandering on the first floor and in other residents’ rooms. The resident’s records showed mixed elopement documentation over time. Earlier elopement risk evaluations identified her as at risk, with interventions such as a wander guard, prompt response to door alarms, family notification, and activity involvement. Later documentation showed the wander guard had been discontinued and a 15-minute safety check order had also been discontinued before the elopement event. The care conference and care plan noted that she walked around the unit, used a two-wheeled walker, had severely impaired cognition, and required supervision when leaving the facility. On the day of the event, the resident exited the building without staff awareness. Culinary staff reportedly saw her outside, and RN-A searched the facility and surrounding area but could not locate her. The facility then learned from the resident’s family that she had been found approximately 4.5 miles away at her previous home by neighbors after being missing for about 2.5 hours. The resident had traveled through a busy metropolitan area with double-lane roads and light rail systems, and it was unknown how she got there. Interviews with staff and leadership showed the resident was not wearing a wander guard at the time and that staff believed she was not at risk for elopement because of her recent hip fracture and reduced mobility.
Failure to Report Resident Elopement to State Agency
Penalty
Summary
The facility failed to ensure an elopement was reported to the state agency within 24 hours for one resident. The resident’s annual MDS indicated severely impaired cognition, diagnoses of Alzheimer’s disease with other signs and symptoms involving cognitive functions and awareness, and a surgical repair for hip fracture. The MDS also indicated the resident was ambulatory, used a walker, and was independent with mobility. A progress note documented that culinary staff saw the resident outside the building and RN-A searched for her, notified the police, administrator, and DON, and contacted the hospital while another nurse searched the immediate area. Police arrived, and RN-A later learned from FM-A that the resident was at a neighbor’s house after hitch-hiking to her previous residence. The resident refused to return to the facility and requested hospital evaluation. During interviews, the DON and administrator stated the incident was not reported to the SA because they did not consider it an elopement, citing the resident’s mobility decline and lack of exit-seeking behavior. The facility policy stated that following an elopement, the administrator or designee shall notify the SA as required by state requirements, family or representative, and the physician.
MDS Coding Was Inaccurate for Tube Feeding and Medication Refusal
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was coded accurately for 2 residents reviewed for MDS accuracy. For one resident, the quarterly MDS identified tube feeding in section K even though physician orders from 3/1/26 through 6/24/26 did not identify tube feeding, nutritional assessments dated 3/37/26 and 6/23/26 did not identify tube feeding, and the alteration in nutrition care plan dated 5/28/25 also did not identify tube feeding. During an observation on 6/22/26, the resident was lying in bed with eyes closed and no tube feeding was observed. The MDS coordinator later stated the tube feeding entry was a mistake and should have been coded for IV fluids received while in the hospital, and stated dietary completed section K for nutrition and she checked it for accuracy. For the second resident, the quarterly MDS identified no rejection of care and moderately impaired cognition, but the resident’s MAR showed furosemide was refused 5 of 7 days during the 7-day lookback period. Nursing progress notes documented that the doctor was notified of intermittent medication refusal, and the diuretic care plan did not identify refusal of the medication. During interviews, the MDS coordinator and SS-A described how section E behaviors were reviewed, and SS-A stated she initially coded the resident as refusing care only 1 to 3 days before reviewing the MAR and recognizing the refusal occurred 5 of 7 days. The MDS coordinator later stated the behavior section was coded incorrectly as the resident declined medications within the lookback period.
Incomplete Care Plan for Repeated Diuretic Refusals
Penalty
Summary
The facility failed to develop a complete care plan for a resident with moderately impaired cognition, non-Alzheimer's dementia, hypertension, and adult failure to thrive who frequently refused furosemide, a high-risk diuretic ordered for edema. The resident's quarterly MDS identified that he was independent with bed mobility and wheelchair mobility and needed supervision or touching assistance with lower body dressing. Although the resident had a self-care deficit care plan addressing refusal to wear ted hose and a separate diuretic care plan focused on preventing dehydration, neither plan addressed his repeated refusal of the diuretic medication. The physician ordered furosemide daily for edema, but the MAR showed repeated refusals over multiple months, including 11 of 30 days in April, 23 of 31 days in May, and 18 of 22 days through June 22. A Risk vs Benefits form completed for the resident identified that he refused medications at times and was occasionally noncompliant with cares, and noted increased risk for worsening health condition, unmanaged symptoms, hospitalization, falls, infection, and safety/wellbeing concerns due to refusal of medication and intermittent care. However, that form was not incorporated into the care plan and did not identify resident goals, desired outcomes, alternatives to the diuretic, or specific consequences of refusal such as fluid retention, swelling in the legs, feet or abdomen, elevated blood pressure, or headaches. During the survey, the resident was observed seated in his wheelchair with hard red skin and edema in both lower legs, and his socks were leaving indentations on his legs. He stated the swelling was painful and had been present for five days, and he said staff were not doing anything. Staff interviews reflected that refusals were discussed in general terms and documented, but specific side effects of refusing a diuretic and alternatives were not identified in the care plan. The resident later stated he had historically been told about the risks of not taking the diuretic, but not specifically about the leg swelling he was experiencing, and he said no one had discussed alternatives to diuretics with him.
Care Plan Not Updated to Reflect Resident’s Current Status
Penalty
Summary
The facility failed to revise R12’s care plan to reflect changes in care needs when the resident’s status changed. R12’s significant change MDS identified intact cognition, substantial to maximal assistance with bed mobility, dependence on staff for toileting, and constant bowel and bladder incontinence. R12’s diagnoses included Alzheimer’s disease, diverticulitis of the large intestine, C-diff enterocolitis, and a pressure ulcer of the sacral region. The care plan printed 6/23/26 still identified a current C-diff infection, Vancomycin use, and isolation precautions, but it did not include the Prevlon boot 24/7 intervention for altered skin integrity. The record showed R12 completed antibiotics for C-diff and no longer had loose stools, and contact precautions were removed and replaced with EBP due to wounds, with the care plan reviewed and updated at that time. A later provider order required daily wound rounds for the right lateral malleolus and use of a Prevlon boot 24/7, yet the TAR still directed staff to follow contact precautions due to C-diff every shift, and staff continued signing it off throughout June except for one shift. Observation showed EBP and PPE signage in the room and Prevlon boots on the dresser. RN-B, RN-C, and the DON stated the resident should have been on EBP and that the orders and care plan should have been updated to accurately reflect the resident’s current status, while the facility policy stated the care plan is to be modified and updated as the resident’s condition and care needs change.
Pressure Ulcer Interventions Not Maintained
Penalty
Summary
The facility failed to ensure pressure ulcer interventions were in place for a resident with intact cognition, substantial to maximal assistance needs for bed mobility, dependence for toileting, and bowel and bladder incontinence. The resident had diagnoses including Alzheimer's disease, diabetes, peripheral vascular disease, and a sacral pressure ulcer. The care plan identified altered skin integrity related to current wounds, including a stage 4 coccyx pressure ulcer and an unstageable pressure ulcer on the right outer ankle, and included a pressure air mattress to bed, but it did not include the ordered Prevlon boot 24/7 intervention for skin integrity. The resident's provider orders included an air mattress for wound care and, later, daily wound rounds for the right lateral malleolus with use of a Prevlon boot 24/7. During observations, the resident was found in bed without the boots on, without a pillow under the legs, and with the feet not offloaded. The air mattress controller repeatedly showed a yellow flashing light indicating low pressure, and staff did not address the malfunction during multiple observations. Wound care supplies were present in the room, but staff interactions focused on other tasks, such as incontinent care, pain medication, and dressing changes, without correcting the air mattress issue. Staff observations and interviews showed inconsistent handling of the boots and air mattress. A nursing assistant removed the boots from the dresser and applied them, stating they had been on all night, while the resident stated she did not have the boots overnight and would not refuse them. Staff also left the room after repositioning, checking supplies, or providing care without checking the air mattress function. The DON, administrator, and other staff observed the mattress controller sliding and still flashing low pressure, but none addressed the malfunction. The DON later stated pressure ulcer prevention interventions should be in place as ordered, and maintenance found the bed malfunctioning and replaced the air mattress.
Inaccurate supplement intake documentation for resident at nutritional risk
Penalty
Summary
The facility failed to ensure that one resident with diabetes mellitus, end stage renal disease, dialysis, and a therapeutic diet received appropriate nutrition assessment and support while at risk for weight loss and dehydration. The resident’s quarterly MDS indicated intact cognition, independence with eating, dialysis, and a therapeutic diet. The care plan identified risks for hypo/hyperglycemia, dehydration, and nutritional problems related to protein calorie malnutrition, with directions to monitor diet compliance, encourage adequate fluid intake, and provide supplements as ordered. A clinical nutrition evaluation documented significant weight loss and no prescribed weight-loss regimen, and provider orders included a 1500 ml fluid restriction with specific fluid allotments and daily Ensure Clear for unplanned weight loss. The resident’s June TAR documented 100% consumption of Ensure Clear every morning, but observation showed 19 unopened Ensure bottles and one opened, half-empty bottle stored in the resident’s room. The CSD stated nursing assistants were expected to round after meals, note dietary and fluid amounts, and notify the nurse, while the DON and RN-B confirmed the bottles were present and that culinary staff included an Ensure with breakfast daily. The resident stated he did not drink all of the Ensure because he was concerned about its effect on blood glucose and said he typically consumed one bottle every couple of days. The RD stated she relied on EMR documentation to assess and adjust nutrition plans and was not aware of the resident’s reluctance to consume the supplement; she said she would have changed to a more diabetic-friendly supplement if she had known. The DON stated staff were expected to document supplement intake accurately so the RD would have accurate information for assessment and nutrition planning.
Dialysis Access Monitoring Not Performed Correctly
Penalty
Summary
The facility failed to provide appropriate monitoring of a resident’s dialysis access site for one resident who required dialysis services. The resident had intact cognition, diabetes mellitus, and end stage renal disease, and the care plan directed staff to monitor the central dialysis catheter port site for bleeding every shift. Provider orders included review of post-dialysis treatment reports, monitoring the dialysis site for bleeding, and vital signs after dialysis, but did not include monitoring for bruit and thrill or direction to avoid blood pressures on the left arm despite the resident having an AV fistula. Documentation showed the resident’s dialysis access changed from a right chest CVC to a left upper arm AV fistula, with the CVC later removed and the AV fistula confirmed as usable for dialysis. During interviews, nursing staff stated they assessed vital signs, weight, and the dialysis site for bleeding, but were not aware of the AV fistula or the need to assess bruit and thrill and avoid blood pressures on the access arm. The DON stated nurses should know the correct location of the resident’s dialysis access site and assess complications and care according to the type and location of access. The facility policy required assessment before and after dialysis for infection and patency of fistula or graft, including feeling for a thrill, listening for a bruit, and not taking blood pressures on the access arm.
Inaccurate Medical Record Documentation for Resident Intake and Isolation Status
Penalty
Summary
The facility failed to ensure medical records contained accurate documentation for 2 residents reviewed for record accuracy. For one resident with intact cognition, diabetes mellitus, end stage renal disease, dialysis, and a therapeutic diet, the care plan and provider orders directed staff to monitor diet compliance, encourage adequate fluid intake, and provide nutritional supplements. The resident’s clinical nutrition evaluation documented significant recent weight loss, and provider orders specified a daily Ensure Clear and fluid restrictions with intake documentation each shift. However, the resident’s June TAR indicated 100% consumption of Ensure Clear every morning, while observation showed 19 unopened Ensure bottles and one opened bottle stored in the resident’s room. The culinary services director stated staff would round after meals and note dietary and fluid amounts, and the DON and RN-B verified the bottles were present but could not explain why so many were unopened despite the TAR documenting full consumption. The resident stated he did not drink all of the Ensure because of concern about blood glucose and said he consumed one bottle every couple days. For the second resident, the significant change MDS identified intact cognition, substantial/maximal assistance needs, incontinence, and diagnoses including Alzheimer’s disease, diverticulitis, C-diff, and a sacral pressure ulcer. The care plan and TAR continued to show contact precautions for C-diff, with the task signed off three times daily for most of June, even though a progress note stated the resident had completed antibiotics for C-diff, had no more loose stools, and contact precautions were removed, with EBP initiated due to wounds. Staff interviews confirmed the resident no longer had C-diff, and the DON stated the order should have been updated to reflect the resident’s current status.
Failure to Offer Updated Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure 2 of 5 residents, R12 and R27, were offered and/or provided updated pneumococcal vaccination in accordance with CDC guidance. Review of the current CDC pneumococcal vaccine recommendations showed that adults age 65 and older who previously received PCV13 and PPSV23 at age 65 or older may receive PCV20 or PCV21, or no additional pneumococcal vaccines based on shared clinical decision making, and adults age 65 and older who received PCV13 at any age and PPSV23 before age 65 should receive a single dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose. R12's admission MDS indicated R12 was over age 65 and not up to date on pneumococcal vaccination, and the record stated R12 was not offered the pneumococcal vaccination. R12 had diagnoses including DM2, kidney failure, and DVT. Although R12's Resident Vaccine Administration Consent Form stated vaccines would be given per PCP order and CDC guidelines, it also stated a pneumococcal vaccine was not indicated and R12 was up to date. The MICC report showed R12 received PCV13 on 2/9/16 and PPSV23 on 3/17/15, with no evidence of PCV20 or PCV21 administration. R27's admission MDS indicated R27 was older than 50 and younger than 65 and was up to date on pneumococcal vaccination. R27 had diagnoses including coronary artery disease, thyroid disease, and malnutrition. R27's Resident Vaccine Administration Consent Form stated vaccines would be given per PCP order and CDC guidelines, but also stated a pneumococcal vaccine was not indicated and R27 was up to date. The MICC report showed R27 received PPSV23 on 7/30/18, with no evidence of PCV20 or PCV21 administration. During interview, the DON, who was also the IP, stated all residents were assessed on admission for vaccine status using the MIIC report and a pneumococcal vaccination application and would be offered any recommended vaccines, and stated all residents and/or resident representatives should be offered, educated on, and provided all recommended vaccinations. The facility policy required residents to be assessed within 5 days of admission for immunization status and eligibility for pneumococcal vaccine, and within 30 days to be offered the vaccine when indicated.
Failure to Document Indication and Non-Pharmacologic Measures Before PRN Narcotic Use
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management for a resident receiving PRN narcotic medication by not identifying the indication for use and not documenting non-pharmacological interventions prior to administration. The resident had intact cognition and multiple serious diagnoses, including retroperitoneal abscess, acidosis, malnutrition, acute kidney failure, and sepsis. The care plan identified an alteration in comfort related to pain and included interventions such as positioning, rest, and massage as non-medical pain relief. A provider order directed that Oxycodone 5 mg be given by mouth every six hours as needed for pain, but did not specify any further indication. Review of the MAR showed that the resident received PRN Oxycodone on three occasions, with effectiveness recorded as “E” for two doses and “U” (unknown) for one dose. For each of these three administrations, there was no corresponding progress note documenting that the medication was given, the symptoms or pain characteristics the resident was experiencing, or any non-pharmacological interventions that were attempted or offered before administering the narcotic. Interviews with an LPN, an RN, the NP, and the DON all described an expected process that included assessing pain location and intensity using a 0–10 scale, offering and documenting non-pharmacological interventions such as repositioning, ice, heat, food, distraction, and then, if needed, administering PRN pain medication and documenting the time, pain rating, location, characteristics, and effectiveness. The DON confirmed that the electronic medical record for this resident’s Oxycodone administrations did not identify the pain location or any non-pharmaceutical interventions offered or attempted. The facility’s Medication Administration policy required documentation of date and time of PRN administration, dose, route, the complaints or symptoms for which the medication was given, and the results and timing of those results, which were not present in the records reviewed.
Failure to Obtain and Administer Ordered Cranberry and Probiotic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and administer routine medications as ordered by the provider for one resident. The resident had diagnoses including thoracic aortic aneurysm, neurogenic bowel, and neuropathic bladder, with intact cognition on admission. A provider order dated 2/13/26 directed that cranberry 250 mg be given orally once daily for UTI prophylaxis. The February 2026 MAR showed eight missed doses of cranberry on multiple dates, each coded with a “9” indicating “see nursing note.” Nursing notes for those dates documented that the cranberry capsules were on order, not available, that the pharmacy had been called, and that staff were waiting for delivery or house stock. The same resident had a provider order dated 2/14/25 for lactobacillus (probiotic), one capsule once daily for diarrhea. The February and March 2026 MARs showed a total of 20 missed doses of lactobacillus on multiple dates, again coded as “9,” with corresponding nursing notes stating the medication was on order and that staff were awaiting medication from the pharmacy or pending delivery. LPN-A explained that unavailable medications were charted with code 9 and that he would check for re-orders and call the pharmacy if needed; OTC medications and supplements were reportedly available as house stock with a process to request appropriate doses. NP-A stated she should be contacted when residents miss medications and confirmed she had not been notified about the missed cranberry and lactobacillus doses. The DON stated that OTC medications or supplements could be requested via a house stock request form and that a medication error occurs when a medication is not administered as prescribed, consistent with the facility’s Medication Administration policy requiring medications to be given in accordance with written prescriber orders.
Failure to Administer Ordered Magnesium Resulting in Significant Medication Error
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from a significant medication error when an ordered magnesium supplement for hypomagnesemia was not administered for multiple days. The resident had diagnoses including retroperitoneal abscess, acidosis, malnutrition, acute kidney failure, sepsis, and hypomagnesemia, with a low magnesium lab value of 1.3 and instructions from the hospital to monitor and treat accordingly. A provider order dated 3/19/26 directed magnesium 250 mg by mouth daily for hypomagnesemia, but the March MAR showed the resident did not receive magnesium on five consecutive days, each omission coded with a “9” and nursing notes indicating the medication was on order or awaiting delivery from the pharmacy. During this period, nursing documentation repeatedly stated that the magnesium was awaiting medication from the pharmacy, despite magnesium being an OTC supplement stocked in the facility, though not in the 250 mg strength. Staff interviews clarified that when an ordered dose differs from stocked OTC strength, nurses are to complete a house stock OTC request form and contact the provider if the pharmacy cannot provide the ordered medication. In this case, the pharmacy confirmed it had not received a request for magnesium 250 mg, and the DON confirmed she was not notified about the missing doses and only discovered the error later during chart review. The facility’s Medication Administration policy required medications to be administered in accordance with written prescriber orders, and the DON stated that a medication error occurs when a medication is not administered as prescribed. While the resident was not receiving the ordered magnesium, clinical information and provider notes documented ongoing low magnesium levels and related symptoms. A magnesium lab on 3/20/26 was 1.2, and an NP note on 3/23/26 stated the NP did not see that the magnesium had been replaced and ordered magnesium to be added to the next lab draw. Social services notes recorded concerns from therapy and family about the resident’s tiredness, lethargy, poor intake, nausea, and difficulty arousing. On 3/24/26, a critical low magnesium value of 1.0 was reported, and an NP telephone note documented that the resident was on a magnesium supplement but that nursing had not started it because only 400 mg tablets were available and the 250 mg tablets had not been delivered. The Pharm-D stated that, given the resident’s leg pain, fatigue, nausea, and missed five doses of magnesium, this constituted a significant medication error, and the MD and NPs confirmed they had not been contacted about the missed doses as required when medications are unavailable or missed.
Deficiencies in Food Storage, Labeling, and Dishwashing Procedures
Penalty
Summary
Surveyors observed multiple deficiencies in food storage, labeling, and handling within the facility. In the main kitchen, a stand-up freezer contained a pan of beef roast with loose plastic wrap and visible ice crystals, and a refrigerator held cut pineapple and turkey lunch meat without dates, as well as sour cream past its best-by date. The dry storage area had empty chemical buckets with residual contents and holes in the lids stored on the floor. Staff interviews confirmed that open food items should be dated and expired items discarded, and acknowledged that chemical buckets should not be stored near food. On resident care floors, refrigerators and freezers contained several unlabeled and undated food items, including milk, sandwiches with visible mold, thawed frozen meals, bread past its best-by date, and take-out containers. Ice packs were stored alongside food, contrary to staff expectations. Staff interviews revealed uncertainty about responsibility for monitoring and cleaning resident refrigerators, with some believing it was the kitchen staff's duty, while others were unsure or thought it might be activities or housekeeping. The DON confirmed that all food should be labeled with the resident's name and date, and that expired or open items should be discarded after three days. Dishwashing procedures were also found deficient. The dishwasher temperature log was blank, and dietary aides were unaware of the required wash and rinse temperatures or proper monitoring procedures. Observed wash and rinse cycles did not consistently reach the temperatures indicated on posted signage. Staff reported a lack of formal training on dishwashing temperatures, and the Corporate Dietary Director acknowledged that only some staff had received education on this process. Facility policy required labeling and dating of resident food and proper disposal after three days, but a food storage policy was not provided when requested.
Failure to Track Latent TB and Enforce Contact Precautions for Residents on Isolation
Penalty
Summary
The facility failed to properly identify and track a potential infection for a resident diagnosed with latent tuberculosis (TB). The resident, who had cognitive impairment and chronic lymphocytic leukemia, was prescribed rifampin for latent TB, but this diagnosis and antibiotic use were not documented on the facility's Monthly Line Listing Infection Report. The infection preventionist confirmed that the resident was not included in the infection tracking system and was unaware of the need to monitor this case. Additionally, the facility did not ensure that transmission-based precautions were consistently implemented for two residents on contact isolation for MRSA. Observations revealed that staff, including nursing assistants, an LPN, and a social services staff member, entered the shared room of these residents without donning the required personal protective equipment (PPE), despite clear signage on the door instructing staff to wear gowns and gloves. Staff interviews indicated confusion about when PPE was necessary, with some believing it was only required for direct care and not for other interactions such as delivering meal trays or asking questions. The care plans for the residents on contact precautions directed staff to follow enhanced barrier precautions and to don and doff PPE as indicated. However, the observed practices did not align with these instructions or with CDC recommendations, which require PPE for all interactions that may involve contact with the resident or their environment. The facility's infection prevention and control policy also required the use of surveillance tools to recognize infections and the implementation of appropriate isolation precautions, which was not consistently followed.
Failure to Ensure Proper Application of Compression Stockings
Penalty
Summary
The facility failed to ensure that a resident's compression stockings (TED stockings) were applied correctly, as required by physician orders and the resident's care needs. The resident, who had moderately impaired cognition and diagnoses including spondylosis with myelopathy, muscle weakness, and dementia, was noted to be independent with activities of daily living but had a physician's order for TED stockings to be worn during the day and removed at night. Observations on multiple occasions revealed that the resident's TED stockings were rolled down to the ankles, with excess material hanging off the toes, causing indentations and a red area on the right ankle. The resident stated he put on his own TED stockings, but staff were responsible for ensuring they were applied correctly. Interviews with nursing staff and the director of nursing confirmed that, even when a resident prefers to apply their own TED stockings, it is the responsibility of nurses and nursing assistants to ensure the stockings are worn correctly and according to orders. The resident's care plan did not include any information about the use of TED stockings or the resident's preferences regarding them. Additionally, a facility policy regarding the use of TED stockings for edema was requested but not provided.
Failure to Provide Oral Hygiene Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide necessary oral hygiene services for five out of six residents reviewed for activities of daily living. Multiple residents with cognitive impairments and significant medical conditions, such as severe mental impairment, alcoholic cirrhosis, failure to thrive, schizophrenia, and autistic disorder, were observed to lack assistance with oral care. Observations and interviews revealed that oral care supplies were often unopened or missing from residents' rooms, and residents reported not receiving assistance with oral hygiene. Staff interviews indicated uncertainty regarding the use of oral care supplies and the frequency of oral care, with some staff unfamiliar with residents' needs or care plans. Care plans for these residents indicated a need for assistance with personal hygiene, including oral care, but this assistance was not consistently provided. Residents dependent on staff for oral hygiene either did not receive help or only received it sporadically, and some were unaware of how to use the provided supplies. The facility's policy required staff to maintain residents' abilities in activities of daily living, including oral hygiene, but this standard was not met for the residents reviewed.
Failure to Provide Adequate Hydration Consistent with Resident Needs
Penalty
Summary
The facility failed to provide drinks, including water, consistent with the needs and preferences of five out of six residents reviewed for hydration. Multiple residents with varying degrees of cognitive and physical impairment did not have water or other fluids readily available in their rooms outside of meal and medication times. Observations and interviews revealed that residents often relied on staff or visitors to obtain water, and some expressed a desire for water throughout the day. In several cases, residents were dependent on staff for assistance with drinking, but water was not present or accessible in their rooms. One resident's friend provided water during a visit, and another resident reported only receiving fluids with meals and medications. Staff interviews indicated uncertainty about hydration protocols, and one nursing assistant noted the lack of reusable water mugs on the floor, with staff using small disposable cups instead. The care plans and physician orders for these residents included specific instructions for hydration, such as offering fluids between meals and monitoring for signs of dehydration. Despite these directives, observations showed that water was not consistently available, and staff were not always aware of or following hydration protocols. The DON stated that water should be readily available and that staff were expected to check rooms, but this was not observed in practice. Facility policy required maintaining adequate hydration for all residents, but the observed practices did not align with this policy.
Failure to Ensure Beard Nets Worn by Food Preparation Staff
Penalty
Summary
The facility failed to follow infection control guidelines by not ensuring that staff with facial hair wore beard nets while preparing food in the kitchen. During an observation, a cook with a full beard was seen working in the kitchen without a beard net and confirmed that he had prepared food on multiple days without one because the facility was out of beard nets. The cook acknowledged awareness of the requirement to wear a beard net to prevent hair from contaminating food. A dietary aide reported that the kitchen manager was not present because she had left to purchase beard covers. The administrator stated that staff were expected to wear beard covers and should have communicated the supply shortage so that arrangements could be made to obtain more. Facility policy required the use of hair nets and beard restraints to prevent hair from contacting exposed food and clean equipment.
Neglect Due to Delayed Call Light Response and Staff Discouragement
Penalty
Summary
A nursing assistant (NA) failed to respond promptly to a resident's call light and instructed the resident to limit the use of the call light to emergencies only. The resident, who had recently been admitted and was alert and oriented, used the call light frequently for various needs, including personal care, water, pain medication, and wound care. The NA admitted to intentionally delaying responses, sometimes waiting up to ten minutes before checking on the resident, and prioritized other residents' needs over this resident. The NA also communicated to the resident that unless it was an emergency, he should not use the call light as often, citing the resident's confusion and frequent requests as justification. Other staff, including registered nurses and the administrator, were unaware of the NA's actions and stated that such behavior was unacceptable and not in line with facility expectations. The facility's policy defined neglect as the failure to provide necessary goods and services to avoid physical harm, mental anguish, or emotional distress. The incident was identified as neglect, as the resident's needs were not addressed in a timely manner, and the resident was discouraged from seeking assistance through the call light system.
Deficient Care Planning for Residents
Penalty
Summary
The facility failed to ensure comprehensive, person-centered care plans were developed and adjusted as needed for three residents, leading to deficiencies in care planning. Resident 1's care plan lacked focus areas for bowel and bladder incontinence and dental care, despite these issues being identified in the Minimum Data Set (MDS) and Care Area Assessments (CAAs). The resident required substantial assistance for toileting and oral hygiene, experienced occasional bladder incontinence, and was free of natural teeth, yet these needs were not adequately addressed in the care plan. Resident 2's care plan was incomplete, with several focus areas left blank or not completed, including fall risk, alteration in mobility, and self-care deficit. The resident had a history of falls, used high-risk medications, and experienced frequent pain impacting daily activities. Despite these concerns, the care plan lacked specifics and did not address pain management, toileting, or high-risk medication usage. The care plan also failed to reflect the discontinuation of occupational and physical therapy, which were initially included as interventions. Resident 3's care plan was similarly deficient, with several focus areas left blank or not completed, such as alteration in skin integrity, self-care deficit, and alteration in communication. The resident was severely cognitively impaired, required physical assistance, and had multiple medical conditions, including diabetes and a pressure ulcer. Despite these needs, the care plan did not address the resident's right arm pain, activities, or high-risk medication usage. Interviews with staff revealed a lack of comprehensive care planning, with expectations for detailed and updated care plans not being met, increasing the risk of neglect and unmet needs.
Failure to Reassess and Update Care Plan for Pressure Ulcer Risk
Penalty
Summary
The facility failed to comprehensively reassess the pressure ulcer risk and adjust the care plan for a resident who developed an avoidable stage II pressure ulcer on the coccyx. The resident, who was admitted from an acute care hospital, was severely cognitively impaired and required physical assistance with care and mobility. The resident was at risk for pressure ulcers due to total bowel and bladder incontinence, diabetes, aphasia, cerebrovascular accident, dementia, hemiplegia, and seizure disorder. Despite being assessed as at moderate risk for pressure ulcers, the resident was initially free of pressure ulcers upon admission. The resident's care plan included interventions such as using an incontinent product, repositioning every two hours, and routine skin care. However, after the pressure ulcer was identified, the facility did not comprehensively reassess the resident's pressure ulcer risk or update the care plan to reflect the new condition. The care plan lacked specific interventions related to the pressure ulcer, and the nursing staff did not document a comprehensive assessment of the pressure ulcer risk after its discovery. Interviews with staff revealed a lack of awareness and documentation regarding the resident's pressure ulcer and the necessary interventions to prevent further skin breakdown. The facility's policy required a pressure ulcer risk assessment and appropriate preventative measures, such as mobility and repositioning plans, to be implemented. However, the resident's care plan did not include individualized interventions for pressure ulcer prevention, and the staff did not update the care plan or resident care lists after the ulcer was identified. The Director of Nursing acknowledged that the pressure ulcer was avoidable and that the resident's care plan should have included specific interventions to prevent skin breakdown.
Failure to Verify Nurse Aide Registration for Agency Staff
Penalty
Summary
The facility failed to verify the nurse aide registration for an agency nursing assistant (NA-A) before allowing him to work directly with residents. This oversight occurred on NA-A's first shift at the facility, where he provided care to residents, including hygiene, dressing, feeding, and mechanical lift transfers. The staffing coordinator (SC) acknowledged that the shift request for NA-A was last minute, which prevented her from verifying his registration before he began working. The SC relied on an agency electronic portal system to request and verify licensure or nurse aide registration, but due to the specific agency's process, this information was not immediately available. The director of human resources (DHR) stated that she only managed paperwork for facility staff, not agency staff, and expected the SC to handle agency paperwork. The administrator expected both DHR and SC to ensure agency staff met all requirements, including licensure verification, to maintain resident safety. The SC eventually received confirmation of NA-A's active nurse aide registration via email from the agency on the same day, but this was after NA-A had already worked with residents. The facility did not maintain agency staff employee files, as they accessed information through the agency's portal.
Failure to Transcribe and Administer Medication for Fungal Infection
Penalty
Summary
The facility failed to ensure that a medicated powder for a fungal skin infection was transcribed and applied according to provider orders for a resident with skin breakdown. The resident was assessed by a nurse practitioner for moisture-associated skin damage and a rash, and an order was made for Nystatin powder to be applied to specific areas three times a day. However, the order was not transcribed correctly, and the medication was not administered as scheduled, leading to a lack of treatment for several days. The resident's Medication Administration Record (MAR) showed that the Nystatin order was scheduled to start the day after it was ordered, but there were multiple instances where the medication was not administered. The order was not confirmed and revised until several days later, which resulted in the medication not being applied until then. The resident's condition deteriorated during this period, with the rash spreading and requiring more aggressive treatment. Interviews with staff revealed a lack of awareness and communication regarding the missed medication applications. The Director of Nursing and the administrator were unaware of the issue until it was brought to their attention, and the Health Information Assistant and Licensed Practical Nurse involved in the order process could not recall details about the order. The facility's Medication Error Procedure and Medication and Treatment Orders policy were not followed, contributing to the deficiency.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to immediately report allegations of physical abuse to the State Agency within the required two-hour timeframe. A resident, R3, reported that during morning care, staff placed a pillow over her roommate R2's mouth to stop her from screaming. R3 had previously witnessed a similar incident but did not report it because another staff member intervened. On the day of the incident, R3 informed both an LPN and a nursing assistant about her concerns, but neither reported the allegations to management. R2, the resident allegedly abused, was unable to complete a mental status assessment and was dependent on staff for daily activities. Despite R3's report, R2 denied any abuse when questioned by the LPN. The LPN, who spoke Hmong, did not report the allegations because R2 denied them. The nursing assistant also failed to report, assuming the LPN would handle it. The Director of Nursing was unaware of the allegations until informed by the surveyor. The facility did not provide a policy on abuse reporting when requested.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not providing bathing preferences for a resident, identified as R74. The resident's admission Minimum Data Set (MDS) indicated that an interview for preferences, including bathing preferences, should have been conducted, but it was not assessed. The resident was dependent on staff for showering and bathing, and the care plan indicated a weekly bath schedule. However, the care sheet lacked information on when or what type of bath the resident would receive. The resident's medication administration record and treatment administration record showed a bath was to be given within 24 hours of admission and then follow a bath day schedule, but documentation was inconsistent. Interviews and observations revealed that the resident had not received a shower since admission and had only received sponge baths twice. The resident expressed dissatisfaction with the lack of showers and had visible signs of neglect, such as an odor and long, dirty fingernails. Staff interviews indicated that the resident had a bath schedule, but there was confusion and inconsistency in following it. The resident preferred to sleep in and did not like to get up early, which was not accommodated in the bath schedule. The facility's staff, including the director of social services, nursing assistants, and therapists, acknowledged the resident's preferences but failed to document refusals or adjust the care plan accordingly. The director of reimbursement and registered nurse involved in completing the MDS admitted that section F, which includes resident preferences, was not consistently completed. The director of nursing confirmed the importance of knowing resident preferences and updating care plans accordingly but acknowledged the MDS was not completed. The facility lacked a policy regarding preferences, contributing to the oversight in honoring the resident's bathing preferences.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
The facility failed to maintain privacy for two residents during personal care activities. Resident R42, who is cognitively impaired and dependent on staff for various activities of daily living, was observed receiving care with the door shut but the privacy curtain not pulled. This left R42 exposed when an unidentified staff member entered the room, despite the resident being undressed and facing the wall. Similarly, Resident R64, who is cognitively intact but always incontinent and dependent on staff for personal hygiene, was also observed receiving care without the privacy curtain pulled. This resulted in R64's private areas being exposed when several staff members entered the room. The nursing assistant (NA-A) involved in the care of both residents acknowledged that the privacy curtains in the rooms were stuck and not functioning properly, which prevented them from being used to ensure privacy. NA-A had submitted a work order for the repair of the curtains, but the issue had not been resolved at the time of the observations. The Director of Nursing (DON) confirmed that it was the facility's expectation for staff to provide privacy for residents during personal care by using the curtains. However, the facility's resident privacy policy was not provided upon request.
Failure to Maintain Cleanliness of Tube Feeding Equipment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for a resident who was dependent on staff for all activities of daily living and had a feeding tube through which they received more than 50% of their nutrition. The resident had a history of traumatic brain injury, hemiparesis, and aphasia. Observations revealed that the support legs of the tube feeding pump pole had a dried brown substance, identified as enteral feeding liquid, adhered to them. This substance was noted on multiple occasions over several days, indicating a lack of timely cleaning by the nursing staff. Interviews with the nursing staff, including a registered nurse and the nurse manager, confirmed that the pole was dirty and should have been cleaned. The staff acknowledged that it was their responsibility to clean the equipment once a spill was identified. Despite this, the dried substance remained on the pole for several days. The director of nursing also confirmed that the expectation was for nursing staff to clean equipment immediately if it was dirty. However, the facility was unable to provide a cleaning policy regarding tube feeding pump poles when requested.
Failure to Complete Comprehensive Assessment and Implement Resident Preferences
Penalty
Summary
The facility failed to ensure a comprehensive assessment was developed, completed, and implemented for a resident, identified as R74, upon admission and periodically as required. The resident's Minimum Data Set (MDS) indicated intact cognition and dependency on staff for showering and bathing. However, the MDS lacked an assessment of the resident's preferences for bathing, as required under Section F of the Resident Assessment Instrument (RAI) manual. The resident's care plan and care sheet also lacked specific information regarding the type and timing of baths. Interviews and observations revealed that the resident had not received a shower since admission and had only been given sponge baths twice. The resident expressed dissatisfaction with the lack of showers and had an odor and untrimmed fingernails. Staff interviews indicated that the resident had a bath schedule, but documentation of baths or refusals was inconsistent or missing. The resident's preferences for bathing were not incorporated into the care plan, and the MDS section F was not consistently completed. The facility's staff, including the Director of Reimbursement, Registered Nurse, and Licensed Practical Nurse, acknowledged the importance of completing the MDS and incorporating resident preferences into the care plan. However, they admitted that section F of the MDS was not consistently completed, and there was a lack of documentation regarding the resident's bathing schedule and preferences. The Director of Nursing confirmed the absence of a policy regarding the MDS and emphasized the importance of knowing resident preferences.
Failure to Implement Restorative Nursing Program for Resident with Mobility Issues
Penalty
Summary
The facility failed to ensure that a restorative nursing program (RNP) was completed for a resident with mobility issues. The resident, who has a history of peripheral vascular disease, muscle weakness, difficulty in walking, and an acquired absence of the right leg above the knee, was discharged from physical therapy with a plan to continue ambulation through an RNP. Despite the care plan directing staff to assist the resident in ambulating daily with a prosthetic leg, the resident reported not using the prosthetic due to pain and had not walked for four weeks. Interviews with staff revealed inconsistencies in the implementation of the RNP, with some staff unaware of the resident's ambulation status and others noting the resident's refusal to wear the prosthetic. The resident's treatment administration record (TAR) indicated that the RNP order was being completed, but an interdisciplinary team (IDT) note later identified the resident as not appropriate for the program due to refusal to participate, citing pain with the prosthetic fitting. Despite this, the resident expressed a desire to walk and was able to ambulate with assistance after the IDT meeting. The facility's director of nursing stated that staff should follow orders and document refusals appropriately, but there was no restorative nursing program policy provided upon request, indicating a lack of formal guidance for staff.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement adequate interventions to prevent falls for a resident with a history of repeated falls. The resident, identified as R19, had severe cognitive impairment and required extensive assistance for mobility and toileting. Despite being at high risk for falls due to impaired mobility, unsteady gait, and a history of seizures, the facility did not consistently implement or maintain necessary safety interventions, such as a floor mat next to the bed, as outlined in the resident's care plan. R19 experienced multiple falls, including one on 6/12/24, where the resident was found on the floor next to the bed. The interdisciplinary team (IDT) reviewed the incident and added a floor mat as an intervention. However, subsequent observations revealed that the floor mat was not consistently in place, and staff were not following the care plan. On 6/24/24, R19 was observed trying to get out of bed without a floor mat present, despite the care plan indicating its necessity. Interviews with staff, including a licensed practical nurse manager and the director of nursing, revealed a lack of communication and adherence to the care plan. The facility's policy on fall prevention and management was not effectively implemented, as evidenced by the lack of consistent interventions and documentation. The resident's fall risk evaluations and risk management reports highlighted the need for interventions, yet these were not adequately addressed. The failure to maintain the floor mat and ensure staff followed the care plan contributed to the resident's continued risk of falls, demonstrating a deficiency in providing a safe environment for the resident.
Failure to Monitor and Assess Respiratory Status
Penalty
Summary
The facility failed to ensure ongoing monitoring and assessment of a resident's respiratory status and did not provide respiratory medications as indicated. The resident, identified as R50, had a significant change in their Minimum Data Set (MDS) indicating severely impaired cognition and a diagnosis of chronic obstructive pulmonary disease (COPD). Despite the resident's care plan identifying a potential for respiratory distress, it lacked specific interventions for oxygen use. The resident's physician orders included an albuterol inhaler for wheezing or shortness of breath, but the Medication Administration Record (MAR) showed no administration of the inhaler. Observations and interviews revealed that the resident's oxygen use was not properly documented or monitored. On multiple occasions, the resident was found with the nasal cannula improperly placed or on the floor, and there was no respiratory assessment conducted before or after oxygen therapy. The resident's oxygen saturations and respiratory rate had not been checked since a previous date, and there was no order for oxygen use in the electronic medical record, despite a verbal order being given earlier in the month. Staff interviews indicated a lack of awareness and adherence to proper procedures for oxygen use and respiratory assessments. Nursing staff were unsure about the necessity of orders for oxygen use and the appropriateness of using the PRN inhaler for shortness of breath. The facility's standing house orders lacked specific guidelines for respiratory assessments with oxygen use, and a policy for respiratory assessments was not provided upon request.
Failure to Follow Enhanced Barrier Precautions During Tube Feeding
Penalty
Summary
The facility failed to ensure staff utilized enhanced barrier precautions (EBP) for a resident during tube feeding care. The resident, who had a history of stroke, aphasia, diabetes, malnutrition, and was dependent on tube feeding for nutrition, was observed receiving care without the proper use of personal protective equipment (PPE) as required by EBP. The resident's care plan and active orders specified the need for EBP, including the use of gloves and gowns during high contact care activities such as tube feeding. During an observation, an LPN was seen entering the resident's room, wearing gloves but not a gown, and performing tube feeding care, which included handling the feeding tube and associated equipment. Despite the EBP signage on the door and the facility's policy requiring gowns and gloves for residents with indwelling medical devices, the LPN did not adhere to these precautions. The LPN later stated she was informed by an unidentified person that EBP was not necessary for tube feeding care, contradicting the facility's policy and the director of nursing's statement that PPE should be worn in accordance with EBP for device care.
Failure to Document Wound Care Orders
Penalty
Summary
The facility failed to ensure that the wound care provider's treatment orders were properly transcribed into the medical record for a resident with multiple pressure ulcers. The resident, who had severely impaired cognition and required total assistance for bed mobility and transfers, was at risk for developing pressure injuries. Despite having a care plan in place, the plan lacked specific directions for wound care dressing changes. The wound care provider's orders for the resident's left gluteus pressure ulcer were not documented in the electronic medical record (EMR) or the medication and treatment administration records, leading to a lack of continuity in care. Observations revealed that the dressing changes for the left gluteus pressure ulcer were not being documented as ordered. During wound care rounds, it was discovered that the dressing was wet with drainage, prompting a change in the wound care orders. However, these orders were not entered into the EMR, as expected by the nurse practitioner. The director of nursing confirmed the absence of these orders in the EMR, highlighting a breakdown in communication and documentation processes. The facility's policy required that treatment orders be updated in the care plan, which was not adhered to in this case.
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Illustrative
What surveyors actually found near you
We read the 1,062 citations issued within 25 miles in the last 12 months — including the 28 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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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Saint Paul
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Emeralds At St Paul Llc | 0.5 mi | ★★★★★ | 0 | 0 |
| Ebenezer Integrated Care & Rehab | 0.7 mi | ★★★★★ | 6 | 0 |
| Capital View Transitional Care Center | 0.7 mi | ★★★★★ | 1 | 0 |
| Little Sisters Of The Poor | 1 mi | ★★★★★ | 5 | 0 |
| Cerenity Care Center On Humboldt | 2.1 mi | ★★★★★ | 12 | 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 August 2026) and official state health department websites.