14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
West Saint Paul, MN
3-star overall rating with 2-star inspections with $41,555 in total fines with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2000 Oakdale Avenue, West Saint Paul, MN
(651) 554-9558
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
210
Certified beds
Average residents
171
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Akiko Ike
Operator or chain grouping
Approved since
1974-04-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.90
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.42
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.26
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.84
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.79
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.01
CMS adjusted RN staffing hours
Adjusted total hours
4.75
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
41%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Program rank
6,909
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.36
Composite VBP score used to determine payment impact.
Payment multiplier
0.9865
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.07
Baseline 18.16% · Performance 20.01% · Measure score 3.07 · Achievement 3.07 · Improvement 0
Healthcare-associated infections
2.41
Baseline 7.98% · Performance 7.11% · Measure score 2.41 · Achievement 2.41 · Improvement 2.41
Total nurse turnover
3.35
Baseline 39.68% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 0
Adjusted total nurse staffing
3.71
Baseline 3.30 hours · Performance 4.13 hours · Measure score 3.71 · Achievement 3.71 · Improvement 2.85
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.59% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 127 · Observed rate 13.39% · Lower 95% interval 8.04% |
| Discharge to community | 43.58% |
50.57%
7 pts worse
|
No Different than the National Rate · Eligible stays 120 · Observed rate 36.67% · Lower 95% interval 36.91% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 85.71% |
95.27%
9.6 pts worse
|
Numerator 66 · Denominator 77 |
| Falls with major injury | 3.9% |
0.77%
3.1 pts worse
|
Numerator 3 · Denominator 77 |
| Discharge self-care score | 65% |
53.69%
11.3 pts better
|
Numerator 39 · Denominator 60 |
| Discharge mobility score | 46.67% |
50.94%
4.3 pts worse
|
Numerator 28 · Denominator 60 |
| Pressure ulcers or injuries, new or worsened | 1.32% |
2.29%
1 pts better
|
Numerator 1 · Denominator 76 · Adjusted rate 1.14% |
| Healthcare-associated infections requiring hospitalization | 7.11% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 64 · Observed rate 7.81% · Lower 95% interval 3.58% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 253 |
| Staff flu vaccination coverage | 54.87% |
42%
12.9 pts better
|
Numerator 152 · Denominator 277 |
| Discharge function score | 71.67% |
56.45%
15.2 pts better
|
Numerator 43 · Denominator 60 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 97.3% |
96.28%
1 pts better
|
Numerator 36 · Denominator 37 |
| Resident COVID-19 vaccinations up to date | 23.53% |
25.2%
1.7 pts worse
|
Numerator 8 · Denominator 34 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.7
0.3 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.2 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
2.0
1 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
97.3%
0.5 pts worse
|
93.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 96.5% · Q3 98.6% · Q4 93.9% · 4Q avg 96.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.1% |
96.1%
2 pts better
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
3.9%
0.5 pts better
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.8% · Q3 3.5% · Q4 4.6% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.1% |
4.3%
0.8 pts worse
|
11.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 4.0% · Q3 5.6% · Q4 6.0% · 4Q avg 5.1% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
4.1%
0.9 pts worse
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 6.8% · Q3 2.7% · Q4 4.6% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.5% |
12.4%
5.9 pts better
|
19.6%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 9.4% · Q3 4.4% · Q4 5.5% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.0% |
17.5%
0.5 pts worse
|
16.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 24.7% · Q3 10.5% · Q4 11.4% · 4Q avg 18.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.5% |
22.5%
4 pts worse
|
16.3%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.5% · Q2 29.4% · Q3 27.7% · Q4 10.0% · 4Q avg 26.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.7% |
18.6%
4.1 pts worse
|
14.9%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.8% · Q2 15.0% · Q3 21.2% · Q4 15.1% · 4Q avg 22.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
2.3%
1.1 pts better
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.1% · Q3 1.2% · Q4 0.6% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
2.6%
0.4 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.8% · Q3 6.3% · Q4 1.5% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.6% |
24.8%
5.8 pts worse
|
19.8%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.7% · Q2 25.9% · Q3 29.3% · Q4 30.4% · 4Q avg 30.6% |
| Percentage of long-stay residents with pressure ulcers | 7.6% |
5.4%
2.2 pts worse
|
5.1%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 10.3% · Q3 5.5% · Q4 5.2% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.6% |
88.6%
11 pts worse
|
81.7%
4.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 84.7% · Q2 85.3% · Q3 75.1% · Q4 69.1% · 4Q avg 77.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.7% |
14.0%
8.3 pts better
|
12.0%
6.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.7% · Observed 6.0% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
1.9%
0.6 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 1.7% · Q3 2.5% · Q4 2.9% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.4% |
82.7%
4.3 pts worse
|
79.7%
1.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.0% |
23.1%
6.1 pts better
|
23.9%
6.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.0% · Observed 16.4% · Expected 23.0% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Top issue: Infection Control (2 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Top issue: Quality of Life and Care (10 deficiencies)
9 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-01-28
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-31
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Not marked corrected
Fire Safety
Have exits that are accessible at all times.
Not marked corrected
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Not marked corrected
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-12-25
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-12-25
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2022-11-07
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-07
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2022-11-07
Fire Safety
Have exits that are accessible at all times.
Not marked corrected
Fire Safety
Install proper backup exit lighting.
Corrected 2022-11-07
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-07
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-11-07
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-11-07
Fire Safety
Ensure proper storage of liquid oxygen.
Corrected 2022-11-07
Inspection history
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-18
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-22
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-01-28
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-01-28
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2025-01-28
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-01-28
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-01-28
Health
Provide activities to meet all resident's needs.
Corrected 2025-01-28
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-28
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-01-28
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-01-28
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-01-28
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-01-28
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-28
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-09
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-02-09
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-02-09
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-09
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2024-02-09
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-09
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-02-09
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-09
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-09
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-27
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-12-27
Health
Assess the resident when there is a significant change in condition
Corrected 2023-12-27
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-12-27
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-12-27
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-27
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-12-27
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-12-27
Health
Respond appropriately to all alleged violations.
Corrected 2023-10-18
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-26
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-03-21
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-11-08
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-11-08
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-11-08
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2022-11-08
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-11-08
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-11-08
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2022-11-08
Health
Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
Corrected 2022-11-08
Health
Ensure that paid feeding assistants have the training they need.
Corrected 2022-11-08
Penalties and ownership
Fine · fine $41,555
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
W-2 Managing Employee · Individual
Nearby options
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