The Estates at St. Louis Park LLC

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff used hair restraints while serving food. This had the potential to affect all the residents who reside on 2 South wing who receive eat meals.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a resident's preferred activities for individual entertainment were available for 1 of 1 resident (R3) reviewed for activities.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess and monitor a skin condition for 1 of 1 resident (R88) reviewed for red areas on chin. Further, the facility failed to ensure a critical lab was followed up on timely for 1 of 1 resident (R138) reviewed for labs.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure range of motion (ROM) was completed on 2 of 2 residents (R3, R35) reviewed who had limited range of motion. In addition, the facility failed to ensure the regular use of a palm protector for 1 of 1 residents (R3) reviewed for splint/brace use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a scheduled pain medication was available as ordered for 1 of 1 resident (R102) reviewed for pain.

Inspectors wroteBased on interview, and document review, the facility failed to ensure ongoing communication and collaboration with dialysis services for 1 of 1 resident (R138) who had a critically low hemoglobin.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement the baseline care plan developed for 1 of 3 residents (R2, R3 and R4) reviewed. The care plans indicated the residents had cognitive concerns and were to have one-to-one staff care and 15-minute checks. R2 had a fall within hours of admitting to the facility. Upon observation R3 and R4 were not receiving one-to-one cares or 15 minutes checks.

Inspectors wroteBased on interview and record review the facility failed to provide fundamental quality of care of professional standards of practice for 1 of 3 residents reviewed for quality of care. R2 had a fall, and the facility was unable to ensure neurological checks (a critical assessment to identify any potential damage to the brain and nervous system) had been completed.

Inspectors wroteBased on interview and document review, the facility failed to ensure the comprehensive care plan indicated the presence of a ventriculoperitoneal (VP) shunt and include signs and symptoms of VP shunt malfunction for 1 of 3 residents (R1) reviewed for comprehensive care plans.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide care in a manner that promoted dignity for 2 of 3 residents (R1, R6) reviewed for dignity concerns.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R1) remained nothing per oral (NPO), receiving nutrition via tube feeding per his hospital discharge orders.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure physician ordered weights were implemented as ordered for 2 of 3 residents (R3 and R4), reviewed for nutrition.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure residents on a secure memory unit were free from harm for 2 of 2 residents (R82 and R17) reviewed for resident-to-resident abuse. This resulted in actual harm when R17 was struck in the face by R82 causing a subconjunctival hemorrhage of the left eye (broken blood vessels in the eye) requiring emergency medical attention.

Inspectors wroteBased on observation, interview and document review, the facility failed to promote a dignified environment for 3 or 4 residents (108, R2, R49) reviewed for resident rights.

Inspectors wroteBased on observation, interview and document review, the facility failed to promote a dignified home like environment for 6 or 6 residents (R61, R13, R126, R22, R63, R68).

Inspectors wroteBased on observation and interview, facility failed to ensure mediations were kept locked or under direct observation of authorized staff in areas where residents, staff and visitors could access medications. The deficient practice had the potential to affect 32 current residents on the unit.

Inspectors wroteBased on observation, interview, and document review, the facility failed to utilize infection control practices while administering medications through gastrostomy tube for 1 of 1 residents (R93) observed for medication administration, utilize infection control practices while delivering meal trays to resident rooms for 7 of 7 residents (R35, R53, R58, R59, R64, R67, R112) observed for dining, while assisting multiple residents to eat at once for 7 of 33 residents (R2, R3, R14,R23, R33, R55, R80) observed for dining. In addition, the facility failed to implement and maintain enhanced barrier precautions (EBP) for 2 of 2 resident (R16, R93) reviewed for transmission based precautions. Furthermore, the facility failed to mitigate transmission of potential infections in relation to laundering of linens and personal items.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident records which contained private, medical, and personal information were kept private and not accessible to unauthorized personnel for 1 of 1 residents (R35) reviewed for privacy.

Inspectors wroteBased on interview and record review the facility failed to ensure timeliness of person-centered care conferences were conducted to ensure resident goals and preferences were discussed for 1 of 1 residents (R93) reviewed for care conferences.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure routine personal hygiene assistance was provided to 2 of 2 residents (R28 and R56) reviewed for ADLs. In addition, facility failed to implement a communication system to ensure resident needs were met for 1 of 1 resident (R93) whose primary language was not English.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's preferred activities for individual entertainment were available for 1 or 1 residents (R93) reviewed for activities. Additionally, facility failed to comprehensively assess for, and provide, individualized activities for 1 of 1 transitional care unit (TCU) resident (R106).

Inspectors wroteBased on observation, interview and record review, the failed to provide services to maintain and/or prevent loss of range of motion and contracture care for 1 of 1 residents (R93 ) reviewed for limited range of motion. Further, the facility failed to maintain a resident's walking program to prevent any loss of independence, strength or range of motion for 1 of 1 resident (R108) reviewed.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure pain with mobility (i.e., repositioning) was appropriately monitored and comprehensively re-assessed then, if needed, interventions developed to promote comfort with mobility for 1 of 2 residents (R92) reviewed for pain management.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure post-dialysis access site monitoring was consistently completed and documented to provide continuity of care and reduce the risk of complication (i.e., bleeding, infection) for 1 of 1 resident (R49) reviewed for dialysis care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to comprehensively assess history of past trauma and implement care plan interventions to identify triggers for 1 of 1 residents reviewed (R18) whose diagnoses included post-traumatic stress disorder (PTSD).

Inspectors wroteBased on interview and document review, the facility failed to address and respond to the consulting pharmacist's (CP) medication regiment review (MRR) for 2 of 5 residents (R75 and R83) receiving psychotropics (a psychoactive medication taken to exert an effect on the chemical makeup of the brain and nervous system) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review, the facility failed to ensure a resident taking an antipsychotic medication had an appropriate diagnosis for use and was monitored for target behaviors for 1 of 5 residents (R83) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review, the facility failed to implement the current standards of vaccinations regarding pneumonia for 1 of 5 residents (R17) over [AGE] years old whose vaccinations histories were reviewed.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure closet doors in disrepair were reported and acted upon in a timely manner to promote a safe, homelike environment for 1 of 1 resident (R92) reviewed whose closet door was broken with exposed nails present.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a resident call light was within reach for 1 of 3 residents (R3) and failed to ensure call light cords were adequately cleaned for 2 of 3 residents (R1, R3) reviewed for call lights.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide toileting and repositing assistance for a 1 of 1 residents (R3) dependent on staff and failed to follow a resident's preference for getting out of bed due to a lack of Hoyer (a full body mechanical lift used to lift and transfer residents) and sling availability for 2 of 2 resident (R3, R1) reviewed for activities of daily living for dependent residents. This had the potential to affect 15 bariatric residents in the facility who required a Hoyer lift for transfers.

Inspectors wroteBased on observation, interview and document review, the facility failed to preserve resident's dignity for 3 of 4 residents (R1, R3, R4) reviewed for toileting assistance.

Inspectors wroteBased on interview and document review, the facility failed to routinely assess skin conditions and implement interventions for 1 of 1 residents (R1) reviewed for quality of care. This resulted in actual harm to R1 who admitted to the facility following surgical repair of abdomen due to cancer, did not receive wound care for nine days, and was re-hospitalized due to severe sepsis.

Inspectors wroteBased on interview and document review, the facility failed to ensure an allegation of abuse was reported to the State Agency (SA) immediately (within 2 hours) for 2 of 5 residents (R1, R2) reviewed for allegations of resident-to-resident abuse.

Inspectors wroteBased on observation, interview, and document review the facility failed to comprehensively assess for appropriate level of supervision for safety in the community for 1 of 3 residents (R1) who had cognitive impairment and a history falls in the community unsupervised. The facility failures resulted in an immediate jeopardy (IJ) when R1 was assaulted and suffered facial injuries while out in the community. The immediate jeopardy began on 8/20/23, when R1 left the facility without staff awareness, was found by law enforcement 9.3 miles away with facial injuries and transferred to hospital. The immediate jeopardy was identified on 10/5/23, and the administrator was notified on 10/5/23, at 4:14 p.m. The immediate jeopardy was removed on 10/6/23, at 4:02 p.m. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to report a missing vulnerable adult to the State Agency (SA) for 1 of 1 resident (R1) who left the facility without staff awareness and was assaulted while out in the community unsupervised.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure 1 of 20 residents rooms (room [ROOM NUMBER]) was maintained in a way to prevent mold infestation and failed to maintain the ice machine in a sanitary manner which contained a build up of lime and a brown and black substance where 135 residents were identified as potentially receiving ice out of.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide a dignified toileting routine for 1 of 1 resident (R19) who expressed feelings of degradation over the facility toileting process.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure resident was comprehensively assessed for self-administration of medications for 1 of 1 resident (R9), who were observed self-administering medications. R9's quarterly MDS dated [DATE], identified R9 was cognitively intact, and required supervision with ADL's.

Inspectors wroteR68's face sheet dated 5/4/23, indicated R68's diagnoses included hemiplegia (paralysis of one side of the body), major depressive disorder and type II diabetes mellitus. R68's quarterly MDS dated [DATE], indicated R68 required extensive to full physical assistance from another person for activities of daily living (ADL) including bathing, grooming and personal hygiene. R68 was independent with eating after set up by another person. R68's cognition was intact; her speech was unclear but was usually able to make herself understood. R68's care plan with a print date 5/4/23, indicated R68 was cooperative with cares and required assistance with nail care. R68 sometimes scratched herself and would break her skin. Weekly skin inspected dated 5/1/23, indicated R68's nails were trimmed during her bath on 5/1/23. The note failed to indicate if attempts were made to clean under her nails. [...]

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure treatment for edema was completed as ordered by the physician for 1 of 1 residents (R59) reviewed for edema.

Inspectors wroteBased on interview and document review, the facility failed to ensure recommendations for cataract evaluation were acted upon for 1 of 1 resident (R19) reviewed for vision.

Inspectors wroteBased on observation, interview and document review, the facility failed to implement pressure ulcer interventions for 1 of 3 residents (R40) reviewed who were identified as at risk for pressure ulcer development.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure safe medication storage for 1 of 1 residents (R77) who was noted to have medications stored in her room without an order for the specific medication.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide or obtain routine dental services for 1 of 1 residents (R114) reviewed for oral/dental health.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure three years of survey results/complaints were readily accessible. This had the potential to affect all 119 residents, their families and any visitors who may have wished to review the information.

Inspectors wroteBased on interview and document review, the facility failed to notify the Long-Term Care (LTC) Ombudsman of a facility-initiated transfer for 1 of 1 resident (R124) reviewed for hospitalization. This had the potential to affect all 119 residents who resided in the facility.