The Villas At St Paul

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to obtain and administrator routine medications according to the physician orders for 1 of 3 (R1) residents reviewed for medication administration.Findings include:R1's diagnoses list dated 2/13/26 included thoracic aortic aneurysm (a dangerous, often silent, weakening and ballooning of the aorta in the chest), neurogenic bowel (loss of normal bowel function due to nerve damage, causing constipation, incontinence, and abdominal pain and bloating), and neuropathic bladder (nerve damage interrupts signals between the brain, spinal cord, and bladder, causing urinary incontinence or retention).R1's admission Minimum Data Set (MDS) dated [DATE] indicated intact cognition.R1's provider order dated 2/13/26 instructed Cranberry oral capsule, give 250 milligrams (mg) by mouth one time a day for urinary tract infection prophylaxis (prevent or reduce the risk).R1's medication administration record (MAR) for February 2026 indicated R1 did not receive cranberry on…

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 a resident was free from a significant medication error for 1 of 3 residents (R3) reviewed for medication errors. Findings include:R3's diagnoses list dated 3/31/26 included retroperitoneal abscess, acidosis, malnutrition, acute kidney failure, and sepsis.R3's admission Minimum Data Set (MDS) dated [DATE] indicated R3 did not have cognitive impairment R3's hospital Discharge summary dated [DATE] included a diagnosis of hypomagnesemia. R3's magnesium laboratory (lab) result on 3/18/26 was low at 1.3. with instructions to monitor and treat accordingly. Magnesium replacement was ordered. The following order was included in the Start taking these medications list: Magnesium, take 250 milligrams(mg) by mouth daily for hypomagnesemia.R3's provider order dated 3/19/26 instructed Magnesium, take 250 milligrams(mg) by mouth one time a day for hypomagnesemia with a start date of 3/19/26.R3's medication administration record (MAR) for March 2026…

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 expired food items were removed from service, food items were labeled and dated, and food was stored in a manner to prevent cross contamination. Furthermore, the facility failed to ensure dishwasher temperatures were monitored to ensure proper sanitization. This had the potential to impact all residents who reside in the facility. Findings include: Food storage An observation on 3/31/25 at 11:43 a.m., the main kitchen was reviewed. A stand-up freezer contained a silver pan with plastic wrap covering it. The plastic wrap was not secured and was loose and lifted off three sides. The plastic wrap had 2/13 beef roast written on it in black marker. Inside was frozen meat with ice crystals and patches of white frost on it. A stand-up refrigerator was reviewed. Inside contained the following: -a covered, plastic container of cut pineapple with no date. -an opened pack of turkey lunch meat with no date. -two containers of [NAME] cultured…

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 R3 R3's prospective payment system (PPS) 5-day assessment Minimum Data Set (MDS) dated [DATE], indicated intact cognition and reported an open lesion on her foot and indicated she was taking an antibiotic during the lookback period. According to the Center for Disease Control (CDC), enhanced barrier precautions (EBP) are an infection control intervention aimed at reducing the transmission of multidrug resistant organisms (MDRO) used during high contact resident care activities. The CDC states contact precautions are put into place to prevent the spread of infectious agents that are spread by direct or indirect contact with the resident or the resident's environment. The CDC recommends using personal protective equipment (PPE), including gown and gloves, for all interactions that may involve contact with the resident or the resident's environment. The CDC indicates donning PPE when entering the room and discarding before exiting the room is done to contain pathogens, or contagious/infectious organisms. R3's 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 ensure residents compression stockings were applied correctly for 1 of 1 resident (R20) reviewed for edema. R20's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition and diagnoses of spondylosis with myelopathy (cervical region), muscle weakness, and dementia. It further indicated R20 was independent with activities of daily living (ADL) and mobility. R20's physician's order dated 3/31/25, indicated Thrombo-Emobolic Deterrent stockings (TED) on during the day and off at night, every morning and at bedtime. Remove at hour of sleep (HS) and wash and rinse, hang to dry. R20's nursing assistant care sheet (undated), indicated R20 preferred to put TED stocking on himself, staff to check that they are on during the day and off at night. R20's care plan dated 3/25/25, indicated self-care deficit related to increased weakness and failure to thrive with the following interventions: -Independent with dressing…

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 Upon observation, interview, and record review the facility failed provide the necessary services of oral hygiene for 5 of 6 residents (R1, R2, R3, R4, R5) reviewed for activity of daily living. Findings include: R1's admission Minimum Data Set, dated [DATE] indicated R1's Brief Inventory of Mental Status (BIM)s score was 00 indicating R1 was severely mentally impaired. R1 required moderate assistance with oral hygiene and eating. He required maximum assistance with dressing and transferring. R1's pertinent diagnose were alcoholic cirrhosis of the liver (severe liver disease caused by excessive alcohol), adult failure to thrive, and cachexia (weight loss of more than 10% in a person not trying to lose weight. R1's care plan dated 3/13/25 indicated R1 was to receive minimum assistant of 1-2 with personal hygiene. Upon observation and interview on 3/27/25 at 2:18 p.m. R1 was lying in bed wearing a hospital gown, two friends were visiting. A plastic basis was observed in his room with an unopened toothbrush…

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 Upon observation, interview, and record review the facility failed to provide drinks, including water consistent with the resident needs and preferences and sufficient to maintain resident hydration for 5 of 6 residents (R1, R2, R3, R5, and R6) reviewed for hydration. Findings include: R1's Clinical Nutritional assessment dated [DATE] indicated R1's goal was for R1 to remain as nourished and hydrated as possible within the disease process. R1's admission Minimum Data Set, dated [DATE] indicated R1's Brief Inventory of Mental Status (BIM)s score was 00 indicating R1 was severely mentally impaired. R1 required moderate assistance with oral hygiene and eating. He required maximum assistance with dressing and transferring. R1's pertinent diagnose were alcoholic cirrhosis of the liver (severe liver disease caused by excessive alcohol), adult failure to thrive, and cachexia (weight loss of more than 10% in a person not trying to lose weight. R1's care plan dated 3/13/25 indicated staff was to offer fluids and snacks…

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 follow infection control guidelines to ensure beard nets were worn by staff who prepared food in the kitchen. This practice had the potential to affect all the residents, staff, and visitors who ate food prepared in the kitchen. Findings include: During an observation on 3/4/25 at 12:41 p.m., cook (CK)-A was observed working in the kitchen where food was being prepared by other staff. CK-A had a full beard, was not wearing a beard net and walked by where the food was being prepared. CK-A stated he worked preparing food on 3/4/25 and 3/5/25, without a beard net because the facility was out of them. CK-A stated he knew he was supposed to wear a beard net to prevent hair from getting into the food. During an interview on 3/4/25 at 12:49 p.m., dietary aide (DA)-A stated the kitchen manager was not in the facility as she left to buy beard covers. During an interview on 3/4/25 at 5:08 p.m., the administrator stated she expected staff to wear a beard cover while preparing food, and if the facility did not have a…

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 neglect did not occur when a staff member nursing assistant (NA)-A failed to answer call lights for a resident timely and instructed the resident to not use their call light unless it was an emergency for 1 of 3 residents (R1) reviewed for neglect. Findings include: R1's admission Minimum Data Set (MDS) comprehensive assessment was not completed as R1 was in the facility just over 24 hours. R1's 48-hour care plan was not completed as he had been in the facility just over 24 hours. R1's progress notes dated 2/26/25 at 11:05 p.m., indicated R1 was admitted on [DATE] around 6:30 p.m., and was alert and oriented. R1's progress notes dated 2/27/25 at 9:30 a.m., indicated staff offered R1 psychiatric services due to R1 had fears related to health and his recent amputation. R1's progress note dated 2/27/25 at 5:31 p.m., indicated R1 called 911 to go to the hospital and left the facility at 6:40 p.m. on 2/27/25. During an interview on 3/4/25 at 2:20…

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 and adjusted as needed to promote continuity of care for 3 of 3 residents (R1, R2, and R3) reviewed for care planning. Findings include: R1's admission Minimum Data Set (MDS), dated [DATE], identified R1 admitted on [DATE] and was cognitively intact. The MDS outlined R1 required substantial physical assistance for toileting and setup/clean up assistance for oral hygiene. The MDS indicated R1 experienced occasional bladder incontinence and frequent bowel incontinence and was free of natural teeth. Further, the MDS outlined multiple Care Area Assessments (CAAs: items to have an in-depth review completed) were triggered for R1 which included, but was not limited to, Urinary Incontinence and Dental Care. Urinary incontinence was identified to be addressed in the care plan for improvement and to minimize risks. Dental care was identified to be addressed in the care plan to maintain current…

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 reassess pressure ulcer risk and adjust the care plan for 1 of 1 residents (R3) who developed an avoidable stage ll (i.e., partial thickness tissue loss) pressure ulcer to R3's coccyx (tailbone area). Findings include: R3's admission MDS and Optional State Assessment (OSA) Item Set, both dated 7/18/24, identified R3 admitted on [DATE] from an acute care hospital and was severely cognitively impaired with unclear speech and impairments with understanding and verbalization of need. The MDS outlined R3 required physical assist with cares and mobility, demonstrated total bowel and bladder incontinence, was diagnosed with diabetes, aphasia (impaired communication ability), cerebrovascular accident (CVA - stroke), dementia, diabetes, hemiplegia/paresis (weakness on one side of body), and seizure disorder, and was at risk for pressure ulcers based on clinical assessment and a formal assessment instrument/tool in which R3 utilized a pressure…

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 verify nurse aide registration for 1 of 1 agency nursing assistants (NA-A) prior to allowing the individual to serve as a nurse aide and work directly with facility residents. This had the potential to affect all residents on the transitional care unit (TCU). Findings include: During an interview on 9/20/24 at 1:17 p.m., NA-A stated this was his first time working at the facility. NA-A identified he provided cares that morning to residents that included tasks such as hygiene and dressing cares, feeding, and mechanical lift transfers. When interviewed on 9/20/24 at 2:10 p.m., staffing coordinator (SC) stated 9/20/24 was NA-A's first shift and his agency staffing request was last minute. SC identified the director of human resources (DHR) managed facility staff and agency paperwork. During an interview on 9/20/24 at 2:25 p.m., DHR stated she only managed facility staff paperwork and did not follow-up on paperwork related to agency staff. She explained agency paperwork was SC's responsibility as SC collaborated with the…

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 a medicated powder for a fungal skin infection was transcribed when ordered, and thus applied, in accordance with provider orders for 1 of 3 residents (R1) reviewed for skin breakdown. Findings include: A wound care provider progress note, dated 8/28/24, identified R1 was assessed by nurse practitioner (NP)-A for left gluteus (buttocks) moisture associated skin damage (MASD) with observed peri area and groin intertrigo rash (skin condition caused by friction, heat, and moisture between skin folds). NP-A cleansed and applied Nystatin (anti-fungal medication) to R1's backside. The note directed the continued application of Clortrimazole-Betamethasone cream (anti-fungal medication) as previously ordered; however, did not reflect directions for facility Nystatin use. A Skin and Wound Evaluation form, dated 8/28/24, completed by NP-A, identified R1 was assessed for left gluteus incontinence associated dermatitis (condition that causes swelling and irritation of the skin). The form lacked measurements and the area…

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 immediately report allegations of physical abuse to the State Agency (SA) with two hours for 1 of 1 resident. R3 reported allegations of physical abuse on her roommate R2. R3 reported during an interview that while staff was providing morning cares to R2 they put a pillow over R2's mouth to stop her screaming. R3 had reported the same allegations of physical abuse to licensed practical nurse (LPN)-A and nursing assistant (NA)-A. Neither LPN-A nor NA-A reported the allegations to the management staff at the facility. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE] indicated R2 spoke Hmong. R2's Brief Inventory of Mental Status (BIMs) score was a zero indicating R2 was unable to complete the assessment. R2 was dependent on staff for activities of daily living (ADLs) such as transfers, bed mobility, dressing, toilet use, and personal hygiene. R2's diagnoses included hemiplegia (paralysis of one side of the body), diabetes 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 record review, the facility failed to provide bathing preferences for 1 of 3 residents (R74) reviewed for choices. Findings include: R74's admission Minimum Data Set (MDS) dated [DATE], indicated R74 was in room [ROOM NUMBER]-1 and had intact cognition, did not have delirium, disorganized thinking, altered level of consciousness, hallucinations, delusions, physical, verbal, or other behavioral symptoms, and did not reject care. Additionally, the MDS indicated R74 was dependent on staff for showering and bathing. Further, the MDS indicated an interview for preferences including for receiving a tub, shower, or bed bath should be conducted, however was not assessed. R74's Medical Diagnosis form dated 6/27/24 at 9:53 a.m., indicated the following diagnoses: sepsis, rhabdomyolysis (a muscle injury where muscles break down), encephalopathy (a disturbance of brain function), blindness, and personality disorder. R74's care sheet lacked information when R74 would receive a bath or…

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 privacy was maintained when personal cares was provided for 2 of 2 residents (R42, R64) reviewed for activity of daily living. Findings Include: R42 R42's quarterly Minimum Data Set (MDS) dated [DATE], indicated R42 was cognitively impaired, dependent on staff for toileting, transfers, dressing and personal hygiene. R42's face sheet printed 6/27/24, indicated diagnosis included cerebrovascular disease affecting right dominant side, with hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing). R42's care plan revised on 5/3/23, indicated R42 was to be turned every two to three hours, and staff were to perform peri care after each incontinent episode and as needed. R64 R64's quarterly MDS dated [DATE], indicated R64 was cognitively intact, always incontinent of bowel and bladder and dependent on…

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 a clean and sanitary environment for 1 of 1 resident (R29) reviewed who had enteral feeding liquid spilled on the support legs of the tube feeding (TF) pump pole. Findings include: R29's quarterly Minimum Data Set, dated [DATE], included R29 was dependent on staff for all activities of daily living, had diagnoses of traumatic brain injury, hemiparesis (weakness or the inability to move on one side of the body), and aphasia (the loss of ability to understand or express speech), and also indicated they had a feeding tube through which they received more than 50% of their nutrition. R29's physician order with revision date 6/25/24, indicated to wipe down and sanitize TF pump and pole once a week, every Thursday night shift. During observation on 6/24/24 at 12:19 p.m., R29 was lying in bed in their room with tube feeding running. The tube feeding pump was attached to a pole and there was dried brown substance on 3 of 4 support legs…

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 the comprehensive assessment was developed, completed, and implemented for one of one resident (R74) reviewed for assessments. Findings include: See also F561. The Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.18.11, dated October 2023, indicated the purpose of the manual was to offer clear guidance about how to use the resident assessment instrument (RAI) correctly and effectively to provide appropriate care. The RAI helps nursing home staff gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan. Under the heading, Section F: Preferences for Customary Routine and Activities, indicated the intent was to obtain information regarding the resident's preferences for their daily routine and activities. Further, this is best accomplished when the information is obtained directly from the…

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 the wound care provider's treatment orders were transcribed into the medical record to ensure continuity of care for 1 of 2 (R48) residents reviewed for pressure ulcers. Findings include: R48's quarterly Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition and no rejection of care or behaviors. Diagnoses included stroke, renal insufficiency, diabetes, aphasia (inability to speak), and malnutrition. Total assistance of two staff was required for bed mobility and transfers; and two stage three pressure ulcers, one unstageable pressure ulcer and diabetic foot ulcer were present. R48's significant change Care Area Assessment (CAA) dated 3/22/24, triggered and identified R48 was at risk for developing a pressure injury and other non-pressure related skin concerns. Nursing was directed to continue to monitor for changes in condition, update provider on concerns, complete a weekly skin check and proceed to 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 ensure restorative nursing program (RNP) was completed for 1 of 1 resident (R47) reviewed for mobility. Findings include: R47's face sheet printed 6/27/23 listed the pertinent diagnoses of peripheral vascular disease, muscle weakness, difficulty in walking, acquired absence of right leg above knee, and chronic pain syndrome. R47's quarterly Minimum Data Set, dated [DATE], indicated R47 was cognitively intact, no rejection of care noted, lower extremity impairment on one side, wheelchair use, and no restorative nursing program. R47's Physical Therapy Discharge summary dated [DATE], indicated R47 to have a RNP regarding ambulation after discharge from physical therapy to maintain and increase ease with ambulation. R47's care plan dated 5/23/24 indicated the resident has, an ADL Self Care Performance Deficit r/t Amputation, Impaired balance, Limited Mobility, Pain. Resident has a right leg prosthesis. The plan directed staff to ambulate…

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 1 of 2 residents (R19) with repeated falls had implemented interventions to promote safety and reduce the risk of falls. Findings include: R19's Optional State Assessment (OSA) dated 5/30/24, indicated severe cognitive impairment, did not have behaviors, did not reject care, and required extensive assist for bed mobility, transfers, and toileting. R19's admission Minimum Data Set (MDS) dated [DATE], indicated R19 was frequently incontinent of bowel, had an indwelling catheter, and was not on a toileting program, did not fall in the last month prior to admission, did not fall in the last 2 to 6 months prior to admission, and had not fallen since admission. R19's care area assessment (CAA) summary dated 5/30/24, indicated falls was not triggered. R19's Medical Diagnosis form indicated the following diagnoses: peritoneal abscess, traumatic subdural hemorrhage without loss of consciousness, seizures, anemia, chronic kidney disease,…

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 respiratory status was monitored and assessed on an ongoing basis, and that respiratory medications were provided as indicated for 1 of 1 resident (R50) reviewed with newly prescribed oxygen use. Findings include: R50's significant change Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition, no rejection of care; diagnoses of psychosis, irregular heart rate, high blood pressure, and chronic obstructive pulmonary disease (COPD/chronic inflammatory lung disease that causes obstructed airflow from the lung). No supplemental oxygen use was identified. R50 required extensive assist with bed mobility and was independent with eating but required set up. R50's activities of daily living (ADL) care area assessment (CAA) dated 5/8/24, was triggered because the resident required assist with cares and had impaired cognition. Nursing was directed to monitor for changes in condition, update provider as necessary on…

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 staff utilized enhanced barrier precautions (EBP) for 1 of 2 residents (R48) observed during tube feeding cares. Findings include: R48's quarterly minimum data set (MDS) dated [DATE], identified she was rarely/never understood, was totally dependent on staff for bed mobility and transfers, and extensive assist was required for eating. Diagnoses included stroke, aphasia (loss of speech) and diabetes. R48 had malnutrition and received tube feeding for nutrition. R48's tube feeding care area assessment (CAA) dated 3/22/24, triggered related to receiving tube feeding for all nutritional needs. Staff were directed to continue to administer tube feeding as ordered, monitor for complications and proceed to care plan. R48's care plan dated 3/29/24, identified EBP was placed related to tube feeding and chronic pressure wounds, and staff were directed to don/doff personal protective equipment (PPE) per EBP when high contact cares 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.