18 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Saint Paul, MN
2-star overall rating with 1-star inspections with $13,580 in total fines with 18 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
2237 Commonwealth Avenue, Saint Paul, MN
(651) 632-3503
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
84
Certified beds
Average residents
74
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
1.07
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
3.14
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.97
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.83
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.57
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.89
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.16
CMS adjusted RN staffing hours
Adjusted total hours
5.40
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Program rank
1,607
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55.30
Composite VBP score used to determine payment impact.
Payment multiplier
1.0103
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
4.19
Performance 46.53% · Measure score 4.19 · Achievement 4.19 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
6.87
Baseline 5.62 hours · Performance 5.03 hours · Measure score 6.87 · Achievement 6.87 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.02% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 29 · Observed rate 3.45% · Lower 95% interval 6.18% |
| Discharge to community | 50.27% |
50.57%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 32 · Observed rate 40.63% · Lower 95% interval 37.56% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 33.33% |
95.27%
61.9 pts worse
|
Numerator 8 · Denominator 24 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 24 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 8.33% |
2.29%
6 pts worse
|
Numerator 2 · Denominator 24 · Adjusted rate 8.02% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0.79% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 126 |
| Staff flu vaccination coverage | 35.11% |
42%
6.9 pts worse
|
Numerator 46 · Denominator 131 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
97.3%
1.2 pts better
|
93.4%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 93.8% · 4Q avg 98.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.0% |
3.9%
2.1 pts worse
|
3.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 9.1% · Q3 4.7% · Q4 3.1% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.9% |
4.3%
3.6 pts worse
|
11.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 9.7% · Q3 14.0% · Q4 3.5% · 4Q avg 7.9% |
| Percentage of long-stay residents who lose too much weight | 2.1% |
4.1%
2 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 5.6% · Q4 0.0% · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.2% |
12.4%
3.2 pts better
|
19.6%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 8.5% · Q3 12.7% · Q4 8.5% · 4Q avg 9.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.0% |
17.5%
6.5 pts worse
|
16.7%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.3% · Q2 20.5% · Q3 29.0% · Q4 17.6% · 4Q avg 24.0% · 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 | 12.2% |
22.5%
10.3 pts better
|
16.3%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 10.2% · Q4 4.0% · 4Q avg 12.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.8% |
18.6%
3.8 pts better
|
14.9%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 20.0% · Q3 9.1% · Q4 13.7% · 4Q avg 14.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.7% |
2.3%
0.4 pts worse
|
1.0%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 3.8% · Q3 1.3% · Q4 0.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
2.6%
0.7 pts better
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 1.6% · Q4 4.7% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.1% |
24.8%
6.3 pts worse
|
19.8%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.4% · Q2 29.4% · Q3 41.2% · Q4 19.5% · 4Q avg 31.1% |
| Percentage of long-stay residents with pressure ulcers | 2.8% |
5.4%
2.6 pts better
|
5.1%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.9% · Q3 2.6% · Q4 3.2% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.0% |
88.6%
7.6 pts worse
|
81.7%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 79.1% · Q2 80.9% · Q3 88.7% · Q4 76.5% · 4Q avg 81.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
14.0%
14 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.6% |
1.9%
0.7 pts worse
|
1.6%
1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.0% · Q3 0.0% · Q4 2.5% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.3% |
82.7%
8.6 pts better
|
79.7%
11.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.4% |
23.1%
5.3 pts worse
|
23.9%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.4% · Observed 33.3% · Expected 27.9% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Quality of Life and Care (6 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Top issue: Pharmacy Service (2 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-07-14
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-07-14
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-09-17
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-09-17
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-09-17
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-09-05
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-09-05
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-05
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-05
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-05
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-24
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-24
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-24
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-10-24
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-06
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-10-24
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-10-24
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-10-24
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-24
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-10-24
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-10-24
Fire Safety
Provide rooms that can be unlocked from inside without a key.
Corrected 2023-10-24
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-10-24
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-24
Inspection history
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-06
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-07-03
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-03
Health
Implement a program that monitors antibiotic use.
Corrected 2025-07-03
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-07-03
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-07-03
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-07-03
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-07-03
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-07-03
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-03
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-03
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-07-03
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-07-03
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-07-03
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-07-03
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-07-03
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-07-03
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2025-07-03
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-09
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-17
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-17
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-09-17
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-09-17
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-09-17
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-09-17
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-17
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-17
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-09-17
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-09-17
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-09-17
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 2024-09-17
Health
Provide or obtain dental services for each resident.
Corrected 2024-09-17
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-09-17
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-24
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-24
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-10-24
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-10-24
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-10-24
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-10-24
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-24
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 2023-10-24
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-10-24
Penalties and ownership
Fine · fine $13,580
Fine
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Nearby options
Saint Paul, MN
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Saint Paul, MN
2-star overall rating with 2-star inspections with 18 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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