Little Sisters Of The Poor
Little Sisters Of The Poor in SAINT PAUL, MN — inspection on January 28, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
last transfer and discharge notice received from the facility was on 12/18/24.The facility's
245524 01/28/2026
Little Sisters of the Poor 330 Exchange Street South Saint Paul, MN 55102
During observation on 1/26/26 at 3:45 p.m., R19 was sitting up watching television. R19 was not wearing shoes or socks. R19's toenails were yellowish and about 1 centimeter long from the end of the toe.
During interview on 1/27/26 at 9:31 a.m., nursing assistant (NA)-A stated R19's medical record indicated she received a shower yesterday, Monday 1/26/26.During interview on 1/27/26 at 11:26 a.m., director of nursing (DON) stated a skin assessment needed to be done every week on shower days. DON reviewed R19's EMR and verified there was no documentation of a skin assessment and/or nail care being performed on Monday 1/26/26. DON stated the nursing assistants should cut resident's nails, unless the residents were diabetics. DON stated she expected staff to check the residents' skin and nails every week on shower days, and document in residents EMR.
The concern about not assessing the residents' skin was the staff might not be able to catch a skin or nail issue before it became a problem.During observation and interview on 1/28/26 at 10:50 a.m., DON verified R19's toenails were long and said, they need to be trimmed.Requested a facility's nail care policy and procedure but it was not provided.
245524 01/28/2026
Little Sisters of the Poor 330 Exchange Street South Saint Paul, MN 55102
services of a licensed pharmacist.
destruction was completed in accordance with established policies and procedures to reduce the risk
include:R7's quarterly Minimum Data Set (MDS) date 1/14/26, indicated R7 was cognitively intact, required substantial/maximal assistance with most activities of daily living (ADLs) and mobility, and experienced almost constant pain.
The MDS indicated R7 was taking opioids as scheduled pain medication regimen. R7's diagnoses included Parkinson's disease (neurological disease affecting movement), respiratory failure, and chronic pain.R7's care plan dated 5/27/25, indicated R7 required pain management due to chronic pain as a result of osteoarthritis, kyphosis (condition of humpback), scoliosis (abnormal curvature of the spine), and dorsalgia (pain anywhere in the back). R7's physician orders included:-Fentanyl Transdermal Patch 72 hour 12/mcg/hr.apply 1 patch transdermal every 72 hours for pain.
Order date 4/12/25.-Documentation of removal and destruction of Fentanyl patch by two licensed staff nurses.
Nurse #1 signature every 72 hours for destruction of used patch.
Order date 1/5/25.-Documentation of removal and destruction of Fentanyl patch by two licensed staff nurses.
Nurse #2 signature every 72 hours for destruction of used patch.
Order date 1/5/25. R7's monthly pharmacy consultation report (MRR) dated 11/24/25, indicated, review of eMAR documentation for Fentanyl removal/destruction = 4 of 8 entries have same staff signature.
The MRR indicated acknowledgment with a handwritten Noted to watch and signed on 12/1/25. R7's November 2025 medication administration record (MAR) indicated 4 of 10 entries had the same staff initials documented under removal and destruction of fentanyl patch nurse #1 and nurse #2 on the same dates. On 11/29/25, there was a nurse #1 entry with no corresponding nurse #2 entry. R7's December 2025 MAR indicated 6 of 10 entries had the same staff initials documented under removal and destruction of fentanyl patch nurse #1 and nurse #2 on the same dates. On 12/2/25, there was a nurse #1 entry with no corresponding nurse #2 entry. R7's January 2026 MAR indicated 7 of 10 entries had the same staff initials documented under removal and destruction of fentanyl patch nurse #1 and nurse #2 on the same dates. On 1/28/26, there was a nurse #1 entry with no corresponding nurse #2 entry.When interviewed on 1/28/26 at 10:46 a.m., registered nurse (RN)-B stated the process for fentanyl patch removal was for two nurses to witness the destruction of the patch after removal.
The patch would be placed in a drug disposal container stored under the sink in the med room.
Then each nurse would log in separately and sign off the removal and destruction of the patch in the resident's MAR. RN-B stated she removed R7's fentanyl patch this morning and the nurse from nights had witnessed the disposal, but must have forgotten to log in and sign it off in R7's chart.
When interviewed on 1/28/26 at 11:13 a.m., director of nursing (DON) stated expectation that two staff witness destruction of the fentanyl patch after removal.
They each have to log in and document under a nurse #1 and nurse #2 respectively to indicate the fentanyl patch was removed and destroyed appropriately. DON stated this process required two different staff nurses to complete. DON further stated this process should have been monitored more closely to ensure compliance.
When interview on 1/28/26 at 12:14 p.m., consultant pharmacist (CP) stated expectation that there would be two different nurses witnessing and signing off the destruction of the fentanyl patches after removal. CP stated a breakdown in this process had been identified in the November 2025 MRR and should have been monitored by the facility. CP further stated this process was in place to reduce the likelihood of drug diversion or inappropriate use of the medications by staff.
Facility policy Prescribing, Administration and Disposal of Fentanyl Transdermal Systems dated 9/15/24, indicated, Used fentanyl transdermal system should be folded so that the adhesive side of the patch adheres to itself.Place folded system in commercially available disposal kit and dispose per package directions.
The policy further indicated, Two nurses or a nurse and another professional should witness the disposal of used and unused patches.