St Gertrudes Health & Rehabilitation Center

During observation and interview with R26 on 1/12/26 at 5:01 p.m., R26 was lying in bed with call light out of reach on nightstand next to head of bed. R26 stated she could not see it and wanted assistance to get up out of bed to go to dinner.

Normally I use the call light if I need help. If it is out of reach then I make noise to get attention to get [staff] to answer my pleas.

During observation and interview with nursing assistant (NA)-B on 1/12/26 at 5:04 p.m., NA-B verified R26's call light was out of reach, It should be in reach to ask for help.

During interview with NA-D on 1/15/26 at 6:52 a.m., NA-D stated it was important to place the call light next to patients at all times. If out of reach the residents can fall.

For safety.During interview with registered nurse (RN)-G on 1/15/26 at 7:04 a.m., RN-B stated, [staff] always make sure [call light] is in reach and [residents] know how to use it.During interview with director of nursing (DON) on 1/15/26 at 9:57 a.m., DON stated expectation of staff to place the call light call within reach at all times so residents can call for help if needed.Facility policy titled Call Lights-Call System Activation and Response dated 5/28/2024 identified:Each resident is provided with a means to call staff directly for assistance.

The call system must be accessible to residents while in their bed or other sleeping accommodations within the resident's room.

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St Gertrudes Health & Rehabilitation Center 1850 Sarazin Street Shakopee, MN 55379

limited to receiving treatment and supports for daily living safely.

were maintained at a comfortable temperature between 71 and 81 degrees Fahrenheit for 1 of 1

Minimum Data Set (MDS) assessment, dated 12/22/25, indicated a diagnosis of cerebral infarction (stroke) with intact cognition.

During an interview on 1/12/26 at 5:19 p.m., R57 stated his room was cold. R57 was observed wearing a winter coat while sitting in a recliner chair in his room between the bed and the window which he reported was where he spent the majority of his time. R57 stated he had reported his concerns to staff and had been told this room is always like this. R57 stated, I am froze.

The thermostat on the wall indicated 72.9 degrees Fahrenheit (F). At 5:50 p.m., surveyor obtained temperatures in the room: 66.2 degrees F by the tv, 68.3 degrees F around the chair R57 was sitting in, and 67.7 degrees F between the chair and the wall.

During an interview on 1/12/26 at 5:58 p.m., nursing assistant (NA)-C stated R57 had complained of his room being cold about a week or so ago. NA-C stated he thought a form had been filled out for maintenance to look at R57's room temperature. NA-C verified that R57 was wearing a winter coat due to being cold when he brought him to the bathroom this evening.During a follow up interview on 1/13/25 at 9:55 a.m., R57 stated he did not use his personal refrigerator as it was cold enough in the room to keep items on the counter to keep them cold. On 1/14/26 at 10:46 a.m., surveyor obtained temperatures in R57's room. It was 66.5 degrees F around R57's chair.

During an interview on 1/14/26 at 12:20 p.m., director of maintenance (DOM) stated that he had received a complaint of R57's room being cold last week and had the vendor come out and look at his room. DOM stated after the vendor was out, the room was above 71 degrees F.

The next day, DOM check the room temperature via computer as temperatures can be checked from the thermostats via computer without having to disrupt the residents. He stated the computer indicated the room was above 71 degrees F. DOM and surveyor obtained temperatures in R57's room: the area around R57 was 69.7 degrees F, and the middle of the room was 70.2 degrees. R57's thermostat indicated 72.3. DOM stated R57's room temperatures are not within the required 71-81 degrees F and would call the vendor out again.

During an interview on 1/15/26 at 11:15 a.m., administrator stated temperatures are to be between 71-81 degrees F.

Administrator stated the vendor came out yesterday for R57's room and switched the wires.

Administrator stated the room was currently temping at 74 degrees F where the resident sits.A facility policy on room temperatures was requested and not received.

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St Gertrudes Health & Rehabilitation Center 1850 Sarazin Street Shakopee, MN 55379

During an interview on 1/15/26 at 11:04 a.m., director of nursing (DON) stated the expectation would be any resident on an antipsychotic medication should be getting orthostatic blood pressures done monthly. DON stated it's important to monitor orthostatic blood pressures as antipsychotic medications can affect blood pressures which can increase falls. DON could not find any orthostatic blood pressures documented for R49 the last few months.

A facility policy titled Psychotropic Medication Use, reviewed 9/7/23, indicated When psychotropic medications are ordered, the IDT identifies target behaviors, medication side effects to be monitored and implements a resident centered care plan with both non-pharmacologic and pharmacological interventions.

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St Gertrudes Health & Rehabilitation Center 1850 Sarazin Street Shakopee, MN 55379

During an interview on 1/12/26 at 3:48 a.m., R127 stated she had told multiple staff members, multiple times, that she prefers female caregivers, but that male staff keep coming in and she has to remind that that she would prefer a female.

During an interview on 1/15/26 at 8:32 a.m., nursing assistant (NA)-J stated R127 did like men caring for her and if there was a man working on the unit they would try to switch assignments.

NA-J stated when a resident voiced a preference such as female only care givers staff would pass it along shift to shift via word of mouth.

During an interview on 1/15/25 at 8:39 a.m., clinical manager and registered nurse (RN)-H stated she was unaware that R127 had a preference for female only caregivers, stating she would have expected such a preference to be communicated to her to ensure it was care planned. RN-H stated if she was aware R127 had a preference for female only caregivers she would generally talk with staffing and ensure if there were no female nursing assistants working on the unit that the float NA was a female.

During an interview on 1/15/26 at 8:45 a.m., licensed social worker (LSW)-A stated R127's preference for female only care givers was communicated to them through the hospital prior to R127 being admitted to the care facility.

The Social Services Director (SSD) stated in the same interview that it would be expected that those preferences would be communicated to the nurse manager and care planned as floor staff often float to different units, so it is important to have care plans up to date to ensure preferences are honored and care needs are met. A facility policy titled Comprehensive Assessments and Care Planning, revised 9/27/23, indicated the comprehensive assessment and care plan must include a resident's customary routine and preferences.

245610 01/15/2026

St Gertrudes Health & Rehabilitation Center 1850 Sarazin Street Shakopee, MN 55379

During an interview and observation on 1/12/26 at 2:43 p.m., R45 was observed sitting in a chair in her room. R45 stated that she felt like her toenails needed to be trimmed and confirmed that they were not causing her pain. R45 stated she didn't think anyone had offered to help her cut her toenails since she was admitted in July of this year. R45's toenails were observed to have grown past the end of her toes, with a varying nail length, and some toenail curling was observed.

During an interview on 1/13/26 at 12:45 p.m., registered nurse (RN)-B stated that R45 was not a diabetic, so the aides could assist her with cutting her finger and toenails.

When asked when the last time toenail clipping was completed or where it was documented RN-B stated she was not sure.

During an interview and observation on 1/13/26 at 12:47 p.m., nursing assistant (NA)-C stated he had assisted R45 with her personal care this morning. NA-C was observed to lift R45's blanket, look at her toes, and state her toenails looked like they could use a trim. R45's toenails were observed to have grown past the end of her toes, with a varying nail length, and some toenail curling was observed. NA-C stated he didn't work on this unit very often, so he was not sure if R45 refused to get her toenails trimmed or the last time toenail trimming was completed. NA-C confirmed he had not offered to cut R45's toenails.

During an interview on 1/14/26 at 8:22 a.m., RN-C, the clinical manager for the unit, stated she had reviewed R45's records and did not find evidence that R45 had gotten nail care or refused it recently. RN-C stated staff should either document nail care/nail care refusals in a progress note or on the weekly skin check observation form. RN-C stated she saw that staff had been documenting that it was not applicable to the question of whether R45 had her nails done. RN-C stated that after assessing R45's nails, she felt that they should have been previously cut, so she talked with R45 this week, and R45 had consent to having her toenails trimmed. RN-C stated she was unable to cut all of her toenails, so she was going to ensure a consult was made with podiatry for additional nail care. RN-C stated the nurse was supposed to assess the resident's nails on bath days and ensure that nail care was completed as necessary.The facility's Activities of Daily Living policy dated 7/21 was received but did not include guidance regarding nail care.

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St Gertrudes Health & Rehabilitation Center 1850 Sarazin Street Shakopee, MN 55379

During an interview on 1/14/26 at 8:46 a.m., licensed practical nurse (LPN)-A stated R7 left around 5:00 a.m. for dialysis and arrived back to the care facility around 10:00 a.m. LPN-A stated the facility staff sent along an envelope with the dialysis communication sheet in it but that the facility staff often did not receive the sheet back from dialysis.

During an interview on 1/14/26 at 12:25 p.m., the assistant director of nursing (ADON) stated it was expected that staff send the dialysis communication sheet with residents to dialysis, and the nurse was expected to review the sheet for new orders or residents' status when they returned from dialysis.

During a follow up interview on 1/15/26 at 9:08 a.m., the ADON confirmed the most current dialysis communication sheet for R7 was from October, stating, we send the sheet and it doesn't always come back.

During an interview on 1/15/26 at 10:50 a.m., the director of nursing confirmed it would be expected that the nurses are following up with the dialysis communication sheets, stating, we try our best but there is always communication breakdown.A facility policy titled Dialysis Services via Contracted Vendor, revised 5/28/24, indicated, the licensed nurses have ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.

During interview on 1/15/26 at 1:08 p.m., FSD stated the water softener had been down for weeks, and with that not functioning properly, lime and scale had built up in the heating element of the dishwasher. He stated the water softener was back online as of last Friday, but the dishwasher might not be getting soft water yet as it took a while to work through the system. He stated the scaling was building up pretty badly and the heating element didn't run consistently because of that.

They used lime away and a descaler and reached out to Ecolab tech and there will be a deep scrub on the heating element. FSD stated they had not had a scrub done previously, and it has been an ongoing situation. FSD stated the heating element fluctuated from time to time, and it was a difficult problem because it was inconsistent.

When staff notice the temperature is out of range, they should address the temperature and delime it and go back to normal operation. He stated the facility did not have a 3-compartment sink, and they found the issue on Tuesday and then used full disposable dishware. He indicated the service tech was in the facility this afternoon.

During interview on 1/15/26 at 1:00 p.m., the administrator stated storing uncovered fish filets and hamburger patties was concerning, not only for cleanliness but because it could affect the patients.

Administrator stated she expected the staff to wear hair and beard nets because it was a standard practice, so they did not get hair in the food.

Regarding the storage of scoops on dry goods, the administrator stated the scoops should be stored outside of them.

Regarding the wash machine, the administrator stated the facility needed to have an appropriate temperature to be in regulation.

The Ecolab EC-44 Dishmachine brochure dated 2012, indicated a required wash temperature of 160 degrees F and a rinse temperature of 180 degrees F.

The undated facility policy titled Dishwashing Procedures, indicated the facility will implement dishwashing practices that prevent the spread of food-borne illness.

The dish machine will be operated in accordance with the manufacturer's instructions.

245610 01/15/2026

St Gertrudes Health & Rehabilitation Center 1850 Sarazin Street Shakopee, MN 55379