Inspection Reports for
Little Sisters of the Poor Holy Family Residence
330 Exchange St S, St. Paul, MN 55102, St. Paul, MN
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
149% worse than Minnesota average
Minnesota average: 3.9 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jan 28, 2026
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, discharge procedures, personal hygiene care, pharmaceutical services, and medication management.
Findings
The facility was found deficient in providing required discharge documentation and notifications, ensuring routine personal hygiene care including nail care, and properly documenting narcotic and controlled substance destruction procedures. Deficiencies were noted in discharge summaries, transfer notifications to the Office of the State Long-Term Care Ombudsman, nail care documentation, and fentanyl patch removal and destruction protocols.
Deficiencies (3)
F 0628: The facility failed to provide required discharge documentation and notifications to the resident, receiving facility, and the Office of the State Long-Term Care Ombudsman for 1 of 1 resident reviewed. The discharge summary lacked a recapitulation of the resident's stay, final status summary, and medication reconciliation.
F 0677: The facility failed to ensure routine personal hygiene care, specifically nail care, was provided and documented for 1 of 1 resident reviewed. The resident's toenails were long and yellowish, and no skin or nail care was documented on the shower day.
F 0755: The facility failed to ensure narcotic and controlled substances destruction was completed and documented by two licensed nurses as required for 1 of 1 resident reviewed. Multiple medication administration records showed incomplete or missing signatures for fentanyl patch removal and destruction.
Report Facts
Residents discharged: 5
Residents transferred to hospital: 12
Entries with same staff signature for fentanyl patch removal: 4
Entries with same staff initials documented for fentanyl patch removal: 6
Entries with same staff initials documented for fentanyl patch removal: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN-B | Registered Nurse | Described fentanyl patch removal and destruction process and identified documentation lapses |
| Director of Nursing | Director of Nursing | Provided statements regarding discharge summary deficiencies, nail care expectations, and fentanyl patch destruction procedures |
| Consultant Pharmacist | Consultant Pharmacist | Discussed expectations for fentanyl patch destruction and monitoring of compliance |
| RN-A | Registered Nurse | Stated requirements for discharge orders and summary assessments |
| LPN-A | Licensed Practical Nurse | Stated requirements for discharge orders and summary assessments |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Dec 11, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including respiratory care, dementia care, medication management, antibiotic use, physician notification of abnormal labs, and food safety practices. Deficiencies were generally of minimal harm with few residents affected.
Deficiencies (6)
F 0695: The facility failed to ensure oxygen was administered according to physician orders for 1 of 2 residents reviewed for respiratory care. Documentation and oxygen saturation monitoring were incomplete.
F 0744: The facility failed to comprehensively assess and implement individualized person-centered dementia care for 1 of 2 residents reviewed for dementia care. Behavioral documentation was inconsistent and care plans lacked detail.
F 0756: The facility failed to ensure consultant pharmacist recommendations were acted upon timely for 2 of 5 residents reviewed for unnecessary medications, including prolonged topical antifungal use and lack of gradual dose reduction for antidepressants.
F 0757: The facility failed to ensure a topical antibiotic was transcribed as written and failed to ensure the antibiotic was still necessary for 1 resident reviewed for antibiotic use. Monitoring and tracking of topical antibiotics were inadequate.
F 0773: The facility failed to ensure physician notification of an abnormal blood glucose for 1 resident reviewed for diabetes. Low blood glucose events were not reported to the physician as required by standing orders.
F 0812: The facility failed to ensure open refrigerated items were dated and covered, and expired items were removed from storage. This had the potential to impact all 32 residents residing in the facility.
Report Facts
Residents affected: 32
Blood glucose readings: 52
Blood glucose readings: 69
Blood glucose readings: 62
Blood glucose readings: 78
Medication doses: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-A | Licensed Practical Nurse | Named in relation to failure to notify physician of low blood glucose for resident R29 |
| RN-A | Registered Nurse | Involved in dementia care observations and transfer procedures for resident R2 |
| DON | Director of Nursing | Provided multiple interviews regarding deficiencies in respiratory care, dementia care, medication management, and lab notification |
| NA-A | Nursing Assistant | Observed and interviewed regarding oxygen use for resident R11 and dementia care for resident R2 |
| NA-B | Nursing Assistant | Observed and interviewed regarding dementia care for resident R2 |
| Pharmacist Consultant | Pharmacist Consultant | Interviewed regarding delayed follow-up on pharmacist recommendations |
| Dietary Director | Dietary Director | Interviewed regarding food storage and expired items |
| Cook-A | Cook | Interviewed regarding food storage practices and expired items |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Oct 3, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including resident safety, staffing, training, facility management, and care practices.
Findings
The facility was found to have immediate jeopardy related to failure to properly assess and intervene for residents with wandering and elopement risks, resulting in an actual elopement incident. Additional findings included failure to complete annual performance evaluations and training for nursing assistants, lack of comprehensive facility assessment including staffing and contracted services, absence of a hospital transfer agreement, inaccurate staffing data submission to CMS, and inadequate governance policies and accountability.
Deficiencies (8)
F0689: The facility failed to identify, assess, and implement individualized interventions for wandering and elopement risk for 2 residents, resulting in immediate jeopardy when one resident eloped and was found on a city street.
F0730: The facility failed to complete annual performance evaluations for 4 of 5 nursing assistants employed over one year.
F0837: The facility's governing body failed to establish and implement policies for managing and operating the facility and failed to ensure the administrator was held accountable to the governing body.
F0838: The facility failed to conduct a complete facility-wide assessment including resident acuity, staffing needs by shift, competencies, recruitment and retention plans, and contracted services.
F0843: The facility failed to have a written transfer agreement with a Medicare/Medicaid certified hospital to ensure timely resident transfers.
F0851: The facility failed to submit complete and accurate direct care staffing information to CMS based on payroll and verifiable data for contracted and facility staff.
F0940: The facility failed to develop, implement, and maintain an effective training program for all staff, contracted staff, and volunteers consistent with their roles.
F0947: The facility failed to ensure nurse aides completed 12 hours of annual in-service training and did not provide abuse or dementia training to all nursing assistants.
Report Facts
Deficiencies cited: 8
Contracted direct care hours discrepancy: 224
Contracted direct care hours discrepancy: 244
Contracted direct care hours discrepancy: 268
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA-F | Nursing Assistant | Named in findings for lack of annual performance evaluation and incomplete training |
| NA-G | Nursing Assistant | Named in findings for lack of annual performance evaluation and incomplete training |
| CRN-A | Contracted Registered Nurse | Named in staffing and training findings; worked as unpaid volunteer and direct care provider |
| CRN-B | Contracted Registered Nurse | Named in staffing findings; worked as direct care provider |
| Administrator-A | Administrator and CEO | Named in governance findings as president of governing body and administrator |
| Director of Nursing | Director of Nursing | Named in multiple interviews related to elopement incident, staffing, training, and facility assessment |
| Human Resources Manager | Human Resources Manager | Named in interviews related to staffing, training, and job descriptions |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 7, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to timely report suspected abuse, neglect, or injury involving a resident's fall.
Complaint Details
The complaint involved a failure to report an unwitnessed fall with serious injury for one of three residents reviewed. The allegation was substantiated based on interviews and document review.
Findings
The facility failed to report an unwitnessed fall with serious injury within the required two-hour timeframe to the State Agency for one resident. Staff interviews and policy review confirmed the reporting delay.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to proper authorities within two hours for one resident who sustained a serious injury from a fall.
Report Facts
Number of residents reviewed for falls: 3
Number of stitches: 6
Number of stitches: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| licensed practical nurse (LPN)-A | Stated reporting requirements for resident falls | |
| registered nurse (RN)-A | Stated incident should have been reported immediately | |
| administrator | Acknowledged understanding of reporting timeframe and could not explain delay |
Inspection Report
Census: 38
Deficiencies: 1
Date: Feb 1, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control requirements, specifically regarding the designation of a qualified infection preventionist.
Findings
The facility failed to designate a qualified infection preventionist responsible for the infection prevention and control program. The director of nursing was covering the role without proper training or certification, and recruitment efforts for a qualified infection preventionist were ongoing but unsuccessful.
Deficiencies (1)
F 0882: The facility failed to designate a qualified infection preventionist responsible for the infection prevention and control program. The director of nursing was performing infection control duties without proper training or certification.
Report Facts
Residents affected: 38
Inspection Report
Routine
Deficiencies: 5
Date: Feb 1, 2024
Visit Reason
Routine inspection of the nursing home to assess compliance with health and safety regulations including accident prevention, food safety, infection control, quality assurance, and vaccination policies.
Findings
The facility had multiple deficiencies including failure to assess resident safety with curling iron use, inadequate hot food temperature maintenance, lack of infection preventionist attendance at quality assurance meetings, poor infection control practices including hand hygiene and cleaning of Hoyer lifts, and failure to ensure proper pneumococcal vaccination education and shared clinical discussions for residents.
Deficiencies (5)
F0689: The facility failed to ensure 1 of 3 residents was assessed for safe use of a curling iron and lacked a care plan for its use.
F0812: The facility failed to ensure hot foods were held at 135 degrees Fahrenheit or higher for 1 of 3 steam tables, affecting 12 of 38 residents.
F0868: The Quality Assurance committee failed to ensure required members, including an infection preventionist, attended quarterly meetings, potentially affecting all 38 residents.
F0880: The facility failed to ensure hand hygiene was performed for 1 of 2 residents observed and failed to clean a Hoyer lift between uses for 2 residents.
F0883: The facility failed to ensure clinical shared discussions and education regarding pneumococcal vaccinations according to CDC guidelines for 3 of 5 residents reviewed.
Report Facts
Residents affected: 1
Residents affected: 12
Residents affected: 38
Residents affected: 2
Residents affected: 3
Residents eating in dining room: 12
Total residents: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN)-A | Noted resident used curling iron but no safety assessment was completed | |
| Nursing Assistant (NA)-A | Observed curling iron in resident's bathroom but never saw resident use it | |
| Director of Nursing (DON) | Stated residents should not have curling irons without safety assessment and care plan; also stated no infection preventionist currently employed and no pneumococcal vaccination education process | |
| Cook (C)-A | Provided information on food served and steam table temperatures | |
| Food Service Director (FSD) | Provided information on steam table heating and food temperature monitoring | |
| Dietary Aide (DA)-C | Reported use of smaller steam table and concerns about food temperature | |
| Maintenance Supervisor | Reported no prior knowledge of steam table issues | |
| Nursing Assistant (NA)-B | Reported awareness of curling iron in resident's bathroom and failure to clean Hoyer lift between uses | |
| Nursing Assistant (NA)-A | Observed failure to perform hand hygiene after peri care | |
| Human Resources (HR)-F | Reported no current infection preventionist and recruitment efforts |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Oct 4, 2023
Visit Reason
The inspection was conducted due to complaints and allegations of abuse, neglect, failure to update care plans, inadequate activities programming, lack of qualified activity director, and insufficient staff training on abuse and neglect.
Complaint Details
The investigation was complaint-driven based on allegations of abuse, neglect, failure to update care plans, inadequate activities, lack of qualified activity director, and insufficient staff training. The complaint was substantiated with findings of delayed abuse reporting, incomplete care plans, insufficient activities, unqualified activity director, and missing staff training records.
Findings
The facility failed to timely report suspected abuse and injuries of unknown origin, update care plans after resident moves, provide meaningful activities for residents, employ a qualified activities director, and ensure required abuse, neglect, and exploitation training for staff. Several residents exhibited behavioral and cognitive impairments with inadequate care plan updates and limited engagement in activities.
Deficiencies (5)
F0609: The facility failed to timely report suspected abuse and injuries of unknown origin for 2 residents. Staff delayed reporting an abuse allegation and did not report an injury causing fractured ribs and pneumothorax.
F0657: The facility failed to update the care plan for 1 resident after moving floors and did not include instructions regarding restrictions or monitoring of inappropriate behaviors.
F0679: The facility failed to provide meaningful activities for 3 residents dependent on staff, with observations of residents sleeping or inactive and staff reporting limited or no 1:1 activities.
F0680: The facility failed to have a qualified activities director overseeing the activities program. The assistant activities director lacked certification and required experience.
F0943: The facility failed to ensure required abuse, neglect, and exploitation training was completed for 2 of 4 staff whose personnel records were reviewed.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 3
Staff without required training: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-A | Licensed Practical Nurse | Named in failure to complete required abuse, neglect, and exploitation training |
| NA-A | Nursing Assistant | Named in failure to complete required abuse, neglect, and exploitation training |
| AD-A | Assistant Activities Director | Named as unqualified activities director filling in since 2/2023 |
| HR-A | Human Resource Director | Interviewed regarding training and reporting systems |
| Administrator | Interviewed regarding abuse reporting, activities, and staffing |
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