The Villas at St. Louis Park

Inspectors wroteBased on interview and document review, the facility failed to ensure physician orders for blood pressure monitoring were accurately transcribed, implemented, and recorded in the record to provide continuity of care for 1 of 3 residents (R1) reviewed. R1 had physician orders placed on 6/24/26 to perform manual blood pressure checks (i.e., not using an electronic device) at alternating times which were not correctly placed in the record system and, as a result, not completed in accordance with the order.

Inspectors wroteBased on observation and interview the facility failed to ensure medications were properly labeled to prevent medication errors for 4 residents (R48, R56, R109, and R102) observed during review of medication carts. Additionally, the facility failed to permanently affix two lock boxes used for controlled medications in the medication room refrigerator reviewed for medication storage.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure facial hair was trimmed for 1 of 1 residents (R84) reviewed for dignity. R84's quarterly Minimum Data Set (MDS) dated [DATE], included R84 was cognitively intact. R84's diagnoses included arthritis, stroke, and dementia. R84 had impairment to both upper extremities. R84 required substantial to maximum assistance with personal hygiene, which included shaving. During observation on 2/9/26 at 1:30 p.m., R84 was observed with 1/4 to 1/2 inch long white hairs on her chin. R84 had contractures on both of her hands and commented on how she was unable to open her hands because it was too painful. R84's electronic medical record included a note entered by social worker (SW)-A on 2/9/26 at 3:04 p.m., including SW-A offered to have her face shaved, which resident agreed too. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a self-administration of medications assessment was completed to allow residents to safely administer their own medications for 2 of 2 residents (R37, R75) observed with medications at bedside.

Inspectors wroteBased on interview and document review, the facility failed to ensure a Notice of Medicare Non-Coverage (CMS-10123 - NOMNC) was provided at least two days before the end of a Medicare-covered Part A stay for for 1 of 3 residents (R23) whose Medicare covered Part A stay ended.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure resident rooms were kept in good working condition for 1 of 2 (R82) reviewed for environment.

Inspectors wroteBased on interview and document review, the facility failed to complete regular care conferences for 1 of 1 residents (R9) reviewed for care conferences.

Inspectors wroteBased on observation, interview and document review, the facility failed to maintain fingernails at a reasonable length for 1 of 4 residents (R84) reviewed for activities of daily living (ADLs). R84's quarterly Minimum Data Set (MDS) dated [DATE], included R84 was cognitively intact. R84's diagnoses included arthritis, stroke, and dementia. R84 had impairment to both upper extremities. R84 required substantial to maximum assistance with personal hygiene. During observation on 2/9/26 at 1:30 p.m., R84 was observed having contractures on both of her hands and commented on how she was unable to open her hands because it was too painful. R84's fingernails were long, had uneven, chipping red paint. During interview on 2/11/26 at 11:42 a.m., nursing assistant (NA)-A stated assistance with nail care happened on shower days. [...]

Inspectors wroteBased on interview and document review, the facility failed to update the provider with insulin readings outside of parameters for 1 of 1 residents (R101) reviewed for physician parameters.

Inspectors wroteBased on observation and interview the facility failed to ensure gastrostomy tube water flushes with medication administration were provided per physician orders for 1 of 1 residents (R48) reviewed for tube feedings.

Inspectors wroteBased on observation and interview, the facility failed to ensure oxygen was administered as ordered for 1 of 1 resident (R38) reviewed for oxygen therapy. 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. R38's summary report dated 2/13/26, included an order for oxygen at 2-3 liters per minute (LPM) via nasal cannula continuously to maintain oxygen saturation at 90% or above. During observation on 2/10/26 at 9:28 a.m., R38 was in her wheelchair at the side of her bed with her feet in footrests. R38's oxygen nasal cannula was hanging off of her right ear and not properly placed in her nostrils. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on interview and document review, the facility failed follow up on pharmacist recommendations for 1 of 5 residents (R9) reviewed for monthly pharmacist reviews.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to provide ongoing monitoring, comprehensive assessment, and care planning, and needed care consistent with professional standards of practice, facility policy, and provider orders resulting in risk of serious illness or death related to complications of coronavirus disease 2019 (COVID-19) infections to 1 of 5 residents (R1) identified in Immediate Jeopardy. In addition to the resident in immediate jeopardy, the facility failed to update policies and procedures for comprehensive assessment, monitoring, developing, and revising person-centered care plans, and implement consistent interventions in accordance with professional standards of practice for all respiratory illnesses resulting in no actual harm with potential for more than minimal harm that is not immediate jeopardy for 4 out of 4 residents (R4, R6, R7, R8). [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.