The Villas At St Louis Park

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to implement a system to monitor stored narcotics and complete controlled substance reconciliation for discontinued medications/discharged residents to prevent potential diversion. Additionally, the facility failed to complete medication reconciliation and medication destruction of non controlled medications that were stored in trash bags and boxes throughout the facility. Findings include:During observation and interview on 2/11/26 at 1:52 p.m., approximately 25 cards containing discontinued/expired medications were noted on a shelf in the Care Coordinators (CC) office located in the transitional care unit. CC stated the medication cards were from residents who had discharged or had their orders changed and the medications needed to be destroyed but she didn't have any time to destroy them. During medication storage observation and interview on 2/12/26 at 10:58 a.m., CC stated the facility had previously had two care coordinators who were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed follow up on pharmacist recommendations for 1 of 5 residents (R9) reviewed for monthly pharmacist reviews.Findings include:R9's quarterly Minimum Data Set (MDS) dated [DATE], included R9 was cognitively intact. R9's diagnoses included anxiety, depression, bipolar disorder and schizophrenia. MDS included R9 was taking antipsychotic medication and antianxiety medication. Review of R9's electronic medical record (EMR) included progress notes from the consultant pharmacist indicating recommendations for the facility on 9/8/25, 10/13/25, 11/9/25, 12/7/25, 1/12/26, and 2/8/26. R9's pharmacy recommendation dated 1/12/26 included a recommendation to complete an AIMS assessment (a tool used to monitor and evaluate side effects of certain medications) with a notation that the recommendation was reissued from November 2025. R9's pharmacy recommendation dated 2/8/26, again included a recommendation to complete an AIMS assessment with a notation it was reissued from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to provide physician ordered physical and occupational therapy (PT and OT) services in a timely manner for 1 of 1 residents (R95) reviewed for rehab services. Findings include: R95's admission minimum data set (MDS) dated [DATE], indicated R95 admitted to the facility on [DATE] and had the following diagnosis: hypertension (high blood pressure), hyperlipidemia (high levels of fat in blood) and displaced fracture of left tibial spine (broken ankle bones). The MDS also indicated R95 required substantial/maximal assistance with rolling in bed from side to side, sit to stand, chair/bed-to-chair transfers, toilet transfers, and mobility with wheelchair 50 ft. R95's hospital discharge paperwork dated 12/22/25, indicated an order for referral to physical and occupational therapy services. It further indicated R95 would likely need a Transitional Care Unit (TCU) stay, PT/OT post op. R95's historical care plan with a closed date of 2/3/26, indicated R95 had an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and document review, the facility failed to ensure the Quality Assurance Assessment and Performance Improvement Plan (QAPI) committee effectively sustained ongoing compliance related to repeat citations from past surveys regarding quality of care, infection control, respiratory care, and resident call system which were also identified during this survey. This had the potential to affect all 92 residents residing in the facility.Findings include: Review of the facility CASPER Report updated 1/14/26, identified the facility was cited at F684 for quality of care on the surveys exited 11/2/23 and 1/9/25. See F684: Based on interview and document review, the facility failed to update the provider with insulin readings outside of parameters for 1 of 1 resident (R101) reviewed for physician parameters. Review of the facility CASPER Report updated 1/14/26, identified the facility was cited at F695 on the survey exited 1/9/25. See F695: Based on observation and interview, the facility failed to ensure oxygen orders were administered as ordered for 1 of 1 resident (R38)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure infection control measures were maintained when performing wound care for 1 of 1 resident (R61) reviewed for wound care. Findings include: R61's admission Minimum Data Set (MDS) dated [DATE], indicated R61's cognition was intact and included diagnoses of pressure ulcer of left buttock-stage 3 (a severe, full-thickness wound extending through the skin to the subcutaneous fat layer, appearing as a deep crater), local infection of the skin and subcutaneous tissue, and morbid obesity. R61's historical care plan with a last review date of 12/5/25, included the following: Focus-resident is currently on Enhanced Barrier Precautions (EBP) relate to wound; Interventions- staff to follow enhanced barrier precautions, staff to don/doff personal protective equipment (PPE) per enhanced barrier precautions when providing high contact care. R61's order review history report signed/dated 2/1/26, indicated the following orders: Buttocks-1) Cleanse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure 1 of 5 residents (R11) was offered, educated and/or provided the pneumococcal vaccination series as recommended by the Centers for Disease Control (CDC), who were reviewed for immunizations.Findings include: A CDC Adult Immunization Schedule by age topic dated 08/07/2025, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had not received the complete series of pneumococcal vaccination (i.e., PPSV23, PCV20 and PCV13) or their history was unknown, then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20), 1 dose of PCV-15, or PCV-21. R11's undated face sheet, indicated R11 was [AGE] years of age, admitted to the facility on [DATE], and had the following diagnoses: bipolar disorder, post-traumatic stress disorder, weakness, hypertension (high blood pressure) and chronic kidney disease. R11's Minnesota…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure a call light was within reach for 1 of 1 resident (R38) reviewed for call lights.Findings include:R38's quarterly Minimum Data Set (MDS) dated [DATE], included R38 was cognitively intact, could understand others and could express ideals and wants. R38's diagnoses include heart failure, multiple sclerosis (a chronic condition that can lead to vision loss, numbness, fatigue and mobility issues), and respiratory failure. During observation on 2/10/26 at 9:28 a.m., R38 was in her wheelchair at the side of her bed. Feet were in footrests. R38 was leaning to the right, oxygen nasal cannula was out of nostrils. R38 stated she just got back from somewhere but could not remember where. R38 stated she was tired and looking forward to laying down. R38 stated her call light was somewhere over there while pointing to the opposite side of her bed. Call light cord was wrapped around bed rail on opposite side of bed and out of reach. On 2/10/26 at 9:35 a.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure food was served at a palatable and appetizing temperature for 2 of 2 residents (R39, R51) reviewed for food palatability. This deficient practice had the potential to affect all 93 residents residing in the facility who consumed food from the facility main kitchen. Findings include: R39's quarterly Minimum Data Set (MDS) dated [DATE], indicated R39 had intact cognition and required supervision to eat. R51's quarterly MDS dated [DATE], indicated R1 had intact cognition and was able to feed herself after staff set up her tray. During an interview on 1/6/25 at 1:43 p.m., R51 stated the food did not taste very good and the hot items were usually served cold and the cold items were served warm. During an interview on 1/6/25 at 2:08 p.m., R39 stated the hot food is always cold and the cold food usually is not cold. During an observation on 1/6/25 at 5:45 p.m., multiple trays were being placed on a cart from the main kitchen. At 6:08…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a shared glucometer (blood glucose meter) was disinfected after use for one resident (R71), and failed to performed hand hygiene after removing soiled gloves and prior to donning clean gloves and completing clean tasks during perineal care for 2 of 3 residents (R10, R17) observed during change of incontinent product. Additionally, the facility failed to ensure staff performed hand hygiene between assisting multiple residents in the dining area for 3 of 5 residents (R71, R40, R49) observed in a dining area. Findings include: HH DURING PERINEAL CARE R10's admission Minimum Data Set (MDS) dated [DATE], indicated R10 had intact cognition, required substantial and/or maximal assistance for toileting hygiene and partial and/or moderate assistance to roll left and right, and had diagnoses of cancer, heart failure, hypertension (high blood pressure), renal disease, diabetes mellitus, and respiratory failure. R17's quarterly MDS dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a comprehensive, person-centered care plan was developed to assure individualized interventions and resident-specific targeted behavior monitoring was completed for 1 of 2 residents (R32) reviewed for mood and behavior. Findings include: R32's admission Minimum Data Set (MDS) dated [DATE], indicated R32 was cognitively intact, had no behaviors or rejection of cares, was independent with eating and rolling left and right, and required substantial and/or maximum assistant with lower body dressing and personal hygiene. R32's MDS did not identify R32 took antipsychotic medications. R32's care plan reviewed 1/6/25, indicated they had an alteration in mood and behavior focus area, and directed staff to document mood state and/or behaviors upon occurrence, redirect prn [as needed], provide emotional support, validation, and comfort measures prn, and MDS section D and/or PHQ 9 [patient health questionnaire which screens for depression] would be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure interventions of Prevalon boots to both feet were in place for 1 of 1 residents (R44) reviewed for non-pressure skin conditions. Findings include: A diabetic ulcer is an ulcer, often on the foot, caused by a combination of poor circulation and nerve damage in patients with diabetes. R44's quarterly Minimum Data Set (MDS) dated [DATE], identified R44 was cognitively impaired, had diagnosis of diabetes mellitus (DM) and dementia, had one stage 2 pressure ulcer, and was dependent on staff for activities of daily living (ADL) and mobility. R44's care plan dated 6/10/24, indicated R44 had an alteration on skin integrity related to a diabetic ulcer due to a diabetic ulcer on the left heel. An intervention revised 12/10/24 indicated R44 was to have Prevalon boot on both heels while in bed. R44's Braden scale assessment dated [DATE], identified R44 had slightly limited mobility and was at risk of developing pressure ulcers. R44's [NAME]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to transcribe and follow an oxygen order consistent with current professional standards of practice for 1 of 1 (R17) resident reviewed for oxygen use. Findings include: R17's quarterly MDS dated [DATE], indicated R17 had intact cognition, was dependent on staff for toileting hygiene, required substantial and/or maximal assistance to roll left and right, and had diagnoses of heart failure, urinary tract infection in the last 30 days, asthma, and respiratory failure. The MDS did not note R17's oxygen use. R17's care plan printed 1/7/25, indicated R17 had a focus area of alteration in oxygen and/or gas exchange, respiratory status related to COPD [chronic obstructive pulmonary disease; long disease which causes restricted airflow and breath problems], chronic respiratory failure with hypoxia, restrictive lung disease, and oxygen use. Interventions included monitor oxygen saturation as ordered and prn, administer oxygen as ordered, keep MD…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to comprehensively assess and identify target behaviors to determine the effectiveness of psychotropic medication for 1 of 1 (R32) resident reviewed for mood and/or behavior. Findings include: R32's admission Minimum Data Set (MDS) dated [DATE], indicated R32 was cognitively intact, had no behaviors or rejection of cares, was independent with eating and rolling left and right, and required substantial and/or maximum assistant with lower body dressing and personal hygiene. R32's MDS did not identify R32 took antipsychotic medications. During document review of R32's care plan on 1/6/25, a focus area indicated R32 had an alteration in mood and behavior. The care plan directed staff to document mood state and/or behaviors upon occurrence, redirect prn [as needed], provide emotional support, validation, and comfort measures prn, and MDS section D and/or PHQ 9 [patient health questionnaire which screens for depression] would be conducted per regulation and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure call lights were accessible for 1 of 2 residents (R51) who were reviewed for call light accessibility. Findings include: R51's quarterly Minimum Data Set (MDS) dated [DATE], identified R44 was cognitively intact and had diagnosis of anxiety and depression. Identified R51 was dependent on staff for activities of daily living (ADLs) and mobility. R51's care plan dated 8/22/24, identified R51 had an alteration in behaviors and yelled out, with an intervention dated 12/4/24, to ensure call light was within reach and to answer promptly as this helped reassure R51. During an interview on 1/6/25 at 1:30 p.m., R51 was seated in her wheelchair about 3 ft. away from her bed. The call light was on the floor under R51's bed. R51 stated her call light was left out of reach often and asked to get staff to help her because she could not reach the call light. During an observation on 1/6/25 at 1:40 p.m., licensed practical nurse (LPN)-A entered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure timely follow-up on ordered radiologic studies for 1 of 3 residents (R2) reviewed for radiological services. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 had one unhealed stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.) and treatments including pressure ulcer/injury care. R2's wound care note by nurse practitioner (NP)-A dated 9/3/24, indicated R2 had a stage 4 sacral (located on the sacrum) ulcer. NP-A's treatment plan included wound care to sacrum, application of ointment to the surrounding area, aggressive offloading and repositioning, up for meals only and back in bed side to side, follow wound care team weekly, and order MRI (magnetic resonance imaging, a medical imaging test that produces a detailed picture of the inside of the body). R2's physician orders…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement the baseline care plan developed for 1 of 5 resident (R1) reviewed. R1's care plan indicated he had cognitive concerns, and he was to have one-to-one staff care for him and 15-minute checks. R1 opened a facility fire door seated in his wheelchair and fell from his wheelchair on the concrete outside the facility door. The facility did not follow the safety measures outlined on the care plan. Findings include: R1's nursing progress note dated 10/27/24 at 12:00 p.m. indicated R1 was brought to the facility by emergency medical services (EMS). R1 was alert and oriented only to self. R1 was assist of one staff member with walker and a gait belt. R1 was a fall risk. R1 appeared confused and tried to leave the room towards the nursing stating wanting to return to his previous facility during the assessment. The nurse attempted to reorient and redirect patient. R1 was offered snacks. R1's baseline care plan dated 10/28/24 indicated safety monitoring…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure that written notifications required for transfers were given to the resident and/or resident representative for 1 of 5 residents (R1) reviewed for admission, discharge and transfers. Findings include: R1's quarterly Minimal Data Set (MDS) dated [DATE], indicated R1 was cognitively intact and had diagnoses which included seizures, anxiety and depression. Identified R1 was independent for transfers and activities of daily living (ADLs). R1's care plan dated 6/7/24, stated R1 had a history and diagnosis of substance use. Staff were to monitor and check vitals if R1 was under the influence of a substance. Identified R1 would have an appropriate discharge plan. R1 would make a safe and appropriate decision regarding discharge. Review of R1's progress notes from 4/12/24 to 6/7/24, identified the following: -On 6/6/24 at 8:45 a.m., resident returned to facility this AM around 8 am intoxicated. Resident stated he drank 4 beers from 10 PM to 2 am.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure the resident or resident's representative was informed of the bed hold policy at the time of hospitalization for 1 of 5 residents (R1) reviewed for hospitalization. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1's diagnoses included seizures, anxiety, depression and was cognitively intact. Identified R1 was independent with transfers and activities of daily living (ADLs). R1's care plan dated 6/7/24, identified R1 had a history of and diagnosis of substance use. Staff were to monitor and check vitals if R1 was under the influence of a substance. Identified R1 would have an appropriate discharge plan. R1 would make safe and appropriate decision regarding discharge. Review of R1's progress notes from 4/12/24 to 6/7/24, identified the following: -On 6/6/24 at 12:07 p.m., Resident back from (leave of absence) LOA @8 am. Resident appeared intoxicated. Resident has slurred speech, appears flushed, teary eyes and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure appropriate donning/doffing of personal protective equipment (PPE) was performed in order to prevent the spread of infection for 2 of 2 residents (R3, R26) observed for enhanced barrier precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. In addition, the facility failed to ensure appropriate donning/doffing of PPE was performed and that the door remained closed for 1 of 1 resident (R31) observed for enhanced respiratory precautions (ERP) (used to protect others from illnesses spread through the air). Findings include: Review of Centers for Disease Control and Prevention (CDC) guidance dated 4/1/24, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) indicated Examples of high-contact resident care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to comprehensively assess the use of a restrictive device (bed sheet tied around legs with a knot) as a potential restraint for 1 of 1 resident (R1) reviewed. Findings include: Review of R1's annual Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition, and diagnoses included hypertension, heart failure, diabetes, anxiety disorder, depression, post-traumatic stress disorder, morbidly obese. Further MDS indicated R1 required substantial assistance for activities of daily living (ADL's) which included bed mobility and transfers. MDS did not indicate a use of restraints. Review of R1's skin assessment dated [DATE], indicated no injuries to skin on R1's lower legs where a bed sheet had been placed to restrain legs to assist from falling off the bed per residents request. Review of R1's current physician active orders dated 7/11/24, did not identify an order for a restraint. R1's medical record lacked any evidence a restraint…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately report, within two hours, an allegation of employee to resident abuse to the State Agency (SA) for 1 of 1 (R2) resident who reported an allegation of physical abuse in the facility. Findings include: R2's Minimum Data Set (MDS) dated [DATE], indicated R2 was admitted [DATE] with diagnoses including debility, muscle weakness, heart failure, anemia (low amount of healthy red blood cells), hypertension, diabetes, atrial fibrillation, and coronary artery disease. R2 required maximum assistance with mobility in bed and toileting cares, was dependent on staff for transfers, utilized a wheelchair, and was frequently incontinent of bowel and bladder. R2's last Brief Interview for Mental Status score from MDS dated [DATE], indicated intact cognition with score of 14. A Police report dated 1/15/24 at 4:01 p.m., indicated the reporting officer spoke with the administrator on 1/15/24. The administrator advised the officer they spoke with R2 the same…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a thorough investigation of allegations of employee to resident abuse for 1 of 1 resident (R2) who reported an allegation of abuse. Findings include: R2's Minimum Data Set (MDS) dated [DATE], indicated R2 was admitted [DATE] with diagnoses including debility, muscle weakness, heart failure, anemia, hypertension, diabetes, atrial fibrillation, and coronary artery disease. R2 required maximum assistance with mobility in bed and toileting care, was dependent on staff for transfers, utilized a wheelchair, and was frequently incontinent of bowel and bladder. R2's last Brief Interview for Mental Status score from MDS dated [DATE], indicated intact cognition with score of 14. In an interview on 1/22/24 at 11:41 a.m., R2 stated on Sunday evening, 1/14/24, at approximately 7:30 p.m., nurse aide (NA)-A and an unidentified NA provided hygiene cares. During cares, NA-A rolled R2 to the right facing the wall next to the bed, hit R2 in the back of the head,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and document review, the facility failed to provide the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine for 2 of 5 residents (R26, R66) reviewed for immunizations. Findings include: Review of the Current CDC recommendations 03/15/23, revealed the CDC identified individuals who previously received 23-valent pneumococcal polysaccharide vaccine (PPSV23) and have not received any other pneumococcal conjugate vaccine (e.g., PCV13, PCV15, PCV20) should receive one dose of PCV15 or PCV20 at least one year after receiving the PPSV23. R26's facesheet identified R26 was admitted to facility on 9/3/22. Review of R26's electronic immunization information in their medical record indicated R26 received PPSV23 on 7/25/15. R26's medical record lacked documentation R26 was offered or declined PCV15 or PCV20. R66's facesheet identified R66 was admitted to facility on 4/12/22. Review of R66's electronic immunization information in their medical record indicated R66 declined to consent for the PCV20.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and document review, the facility failed to treat residents in a dignified manner when residents who required assistance with feeding were referred to as feeders during tray pass on the 1 south, transitional care unit (TCU). This had the potential to affect 4 of 4 residents who required assistance with feeding on the TCU. Findings Include: During observation on 11/01/23 at 12:26 p.m., three facility staff were observed passing room trays. The business office manager (BOM) stated to administrative intern (AI), I left that feeders' tray on the cart. During observation on 11/01/23 at 12:30 p.m., nursing assistant (NA)-E mentioned the names of residents who required assist with eating on the unit and referred to them as the feeders. AI also referred to one of the trays belonging to a resident who required assist with feeding as thats a feeder's tray. During interview on 11/01/23 at 12:39 p.m., BOM stated they helped facility staff several times a week when out to meet with residents on the unit as a caring partner. BOM states while out on the unit, they…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to allow active resident and resident representative participation in the development and review of care plans for 2 of 2 residents (R72 and R57) reviewed for care conferences while residing at the facility. Findings include: R72's quarterly Minmum Data Sets (MDS)'s dated 8/30/23, and 6/13/23, identified moderately impaired cognition. R72 had a diagnosis of stroke and required staff assistance with activities of daily living. The MDS's lacked documentation in the section for Participation in Assessment and Goal Setting. R72's significant change MDS's dated 3/13/23, 2/27/23, and 12/9/22, also lacked documentation in the section for Participation in Assessment and Goal Setting. R72's care plan dated 8/31/23, identified a potential alteration in psycho-social well being with an intervention to invite resident and family to care conferences quarterly. R72's Forms section dated 9/1/22 through 10/27/23, lacked documentation care conferences were completed.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to implement care planned interventions for 1 of 2 residents (R35) reviewed for care plans. Findings Include: R35's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition. R35's mood was not assessed. R35 had no psychosis or rejection of care. R35 required extensive assist from staff for hygiene, bed mobility and transfers. R35 had diagnoses of Alzheimer's disease, anxiety, depression and history of a traumatic brain injury. R35 received an antidepressant seven out of seven days. R35's Psych Treatment Plan and Updates dated 6/26/23, identified R35 was last seen by the psychologist 1/2022. R35 was referred currently for evaluation and treatment by their primary care provider and the health care team of the facility. The goals of the evaluation were to assess mood, strategies to mitigate distress and improve quality of life, strategies to manage behaviors secondary to medical and mental health, and recent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to revise a care plan with interventions for positioning for 1 of 2 residents (R42) reviewed for care plans. Findings Include: R42's quarterly Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition. R42 had no rejection of care. R42 had diagnoses of aphasia, Alzheimer's disease, heart failure, obesity, and Parkinsonism. R42 required extensive assist of two staff for bed mobility. R42's activities of daily living (ADL) care plan dated 9/13/22, lacked information on positioning the head of bed. R42's follow up question report dated 10/2/23 through 11/2/23 (nursing assistant interventions) lacked information about positioning the head of bed. R42's hospice communication notes dated 9/20/23 and 10/18/23, identified to keep resident's head of bed elevated to 45 degrees due to apnea. R42's facility order dated 9/20/23, identified to please keep head of bed lifted at 45 degree angle anytime patient is in bed to support…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to provide routine hair washing and combing for 1 of 1 residents (R87) reviewed for activities of daily living (ADLs). Findings include: R87's admission Minimum Data Set (MDS) dated [DATE], indicated she was cognitively intact, required substantial/maximum assistance to roll, dress, and shower, and was dependent on staff for transfers and toileting. R87 had diagnoses of spastic quadriplegic cerebral palsy (the most severe form of cerebral palsy which includes paralysis of both arms and legs), anxiety, and manic depression. R87's Functional Abilities Care Area Assessment (CAA) dated 10/16/23, included R87 needed assistance with activities of daily living related to cerebral palsy. R87's care plan dated 9/28/23, included R87 had an alteration in mobility and require total assistance from staff for bath/shower. R87's Order Review History Report included R87 was scheduled for a weekly bath every Tuesday during the day shift starting 10/9/23.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and document review, the facility failed to ensure positioning was provided as ordered for 1 of 1 residents (R42) reviewed for hospice services. Findings include: R42's quarterly Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition. R42 had no rejection of care. R42 had diagnoses of aphasia, Alzheimer's disease (changes in the brain that cause it to shrink and no longer function), heart failure, obesity, and Parkinsonism (A chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement.). R42 required extensive assist of two staff for bed mobility. R42's activities of daily living (ADL) care plan dated 9/13/22, lacked information on positioning the head of bed. R42's hospice communication notes dated 9/20/23 and 10/18/23, identified to keep resident's head of bed elevated to 45 degrees due to apnea. R42's facility order dated 9/20/23, identified to please keep head of bed lifted at 45 degree angle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure weekly comprehensive skin assessments were completed for 1 of 1 residents (R87) reviewed for pressure ulcer risk. Findings include: R87's admission Minimum Data Set (MDS) dated [DATE], indicated she was cognitively intact, required substantial/maximum assistance to roll left and right, dress, and shower, and was dependent on staff for transfers and toileting. R87 had diagnoses of spastic quadriplegic cerebral palsy (the most severe form of cerebral palsy which includes paralysis of both arms and legs), and osteomyelitis of sacral vertebra with a wound vacuum (infection involving bone in the lower back treated with a dressing and a machine [wound vacuum] which reduces pressure on the wound, pulls fluid from the wound, helps pull the edges together to assist in wound healing). The MDS included R87 was at risk for pressure ulcers and had an unhealed Stage III pressure ulcers (full thickness tissue loss). R87's Pressure Ulcer Care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to provide the ordered services for the behavioral health needs for 1 of 1 resident (R35) reviewed for mood and behavior. Findings Include: R35's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition. R35's mood was not assessed. R35 had no psychosis or rejection of care. R35 required extensive assist from staff for hygiene, bed mobility and transfers. R35 had diagnoses of Alzheimer's disease, anxiety, depression and history of a traumatic brain injury. R35 received an antidepressant medication seven out of seven days. R35's care plan dated 2/8/23, identified she became inconsolable and impulsive when anxious, depressed, or in pain at which point she paced hallways and followed nurses incessantly yelling at them and would yell out help me repeatedly. R35's goals were to show a decrease in negative behaviors. Interventions included psychogeriatic consult as indicated. R35's care plan lacked interventions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure non-pharmacological interventions were attempted and recorded prior to the administration of as-needed (PRN) psychotropic medication to help facilitate person-centered care planning and reduce the risk of complication (i.e., sedation) for 1 of 5 residents (R42) reviewed for unnecessary medication use. Findings include: R42's quarterly Minimum Data Set (MDS), dated [DATE], identified R42 had severe cognitive impairment but demonstrated no recorded behaviors (i.e., wandering, rejection of care, physical behaviors, verbal behaviors) during the review period. Further, the MDS outlined R42 had several medical diagnoses including high blood pressure, Parkinson's Disease, and Alzheimer's Disease. R42's Order Summary Report, printed 11/2/23, identified R42's current physician ordered medications which included Seroquel (anti-psychotic medication) 12.5 milligrams (mg) daily for psychotic disorder, Depakote (anti-convulsant medication) 250…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure gloves were changed after providing perianal cares during a bed bath for 2 of 2 resident (R7, R12). Findings include: R7's annual minimum data set (MDS), dated [DATE], indicated R7 was cognitively intact and required extensive assist of two staff with bed mobility, dressing, and personal hygiene. R7's face sheet included diagnoses of rheumatoid arthritis (an autoimmune, inflammatory disease, meaning that your immune system attacks healthy cells in your body by mistake, causing inflammation-painful swelling), unilateral primary osteoarthritis of right knee (the bones in your knee joint rub together, causing friction that makes your knees hurt, become stiff or swell) and type 2 diabetes mellitus. R7's care plan initiated 9/8/2022, indicated acitivities of daily living self care performance deficit related to failure to thrive and required assistance with bathing, toileting and personal hygiene. During observation of bed bath on 11/1/23 at 9:38 a.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure resident bathroom call light cords were within reach from the bathroom floor for 1 of 1 residents (R36) reviewed for call lights. Findings include: R36's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and partial to moderate assistance was required with toileting and upper body dressing. R36 had no rejection of care. R36 had diagnoses of dementia, cataracts, and macular degeneration. R36 had one fall without injury since the last MDS. R36's care plan dated 6/25/23, identified R36 was at risk for falls and had actual falls related to weakness, self-transfers, and gait decline. The goal was to be free of minor injury through the review date. Interventions included anticipate and meet the resident's needs and ensure call light is within reach and encourage the resident to use it for assistance as needed. R36's Incident Review and Analysis dated 10/22/23, identified R36 was found on the floor and the causal factor was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to maintain a clean, safe, and homelike environment when holes were observed in the sheetrock of a shared bedroom of R6 and R75. In addition, two large holes were noted on bathroom door of shared bedroom of R12 and R70. This had the potential to affect 4 of 4 (R6, R12, R70, R70) residents. Findings include: During observation on 11/1/23 at 7:59 a.m., cracked and broken sheetrock observed on bedroom wall for R6 and R75 who share a room. A hole the size of a baseball was observed directly opposite of where door handle meets the wall when door is opened. The sheetrock was visibly cracked about 12 inches above and below the hole in the wall. During interview with R6 on 11/1/23 at 7:59 a.m., R6 stated he did not know when the broken sheetrock and hole had been there. During observation on 11/1/23 at 8:13 a.m., two holes were noted in the hollow bathroom door facing R12 and R70's bedroom. Both holes were parallel to each other. One hole was observed directly opposite of where the door from the hallway opens into the bedroom. Another…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure residents were provided care in a dignified and respectful manner for 2 of 4 residents (R2, R4) who were observed during care interactions. Findings include R2's Face Sheet identified R2 had diagnoses that included multiple sclerosis, abnormalities of gait and mobility, anxiety, and adult failure to thrive. R2's quarterly Minimum data Set (MDS) dated [DATE], identified R2 was cognitive, required two person assist for transferring and one person assist for dressing, toileting and personal hygiene. R2 was always incontinent of bowel and bladder. R2's care plan dated 4/25/23 identified R2's alteration in comfort and resident is to receive adequate relief from pain as evidence by verbalization and freedom from signs/symptoms of non verbal indicators. Staff to provide non medicinal forms of pain relief such as positioning, rest and massage, and to encourage resident to verbalize discomfort. During interview on 9/7/23 at 11:20 a.m., R2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure activities of daily living (ADLs) were provided, for 3 of 5 residents (R2, R1, R4) reviewed, who required staff assistance for shaving, oral care, and personal hygiene. Findings include R2 Face Sheet identified R2 had diagnoses that included multiple sclerosis, abnormalities of gait and mobility, anxiety, and adult failure to thrive. R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 did not have cognitive impairment and did not identify rejection/refusal of care behaviors. R2 required two person assist for transferring and one person assist for dressing, toileting and personal hygiene. R2 was always incontinent of bowel and bladder. R2's care plan dated [DATE] identified R2's alteration in mobility. Staff were to complete bed mobility, dressing and toileting with extensive assist of 1-2 staff members, eating with set up assist, and assist of one to two staff members dependent on R2's fatigue level. During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, document review the facility failed to follow the care plan and physician orders for pressure reducing/relieving interventions to prevent or mitigate the risk of deterioration or new pressure ulcer development for 1 of 3 residents (R4) who had impaired skin integrity and was at high risk for pressure ulcers. Findings include R4's Face Sheet identified R4 had diagnoses that included severe protein-calorie malnutrition, diabetes, unspecified anemia, disorder of the skin and subcutaneous tissue and cutaneous abscess of foot. R4's significant change Minimum Data Set (MDS) dated [DATE], identified R4 did not have cognitive impairment. R4 required two person assist for bed mobility, transferring, toileting and dressing. R4 was not on a toileting program and was always incontinent of bowel and bladder. R4 was at risk of developing pressure ulcers and had no unhealed pressure ulcers. R4 required pressure reducing device for chair/bed and required application of non-surgical dressings.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.