The Villas at St. Paul

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide adequate supervision to prevent elopement for 1 of 1 residents (R37) who was reviewed for elopement. This resulted in Immediate Jeopardy (IJ) for R37 when she left the facility and was found approximately 4.5 miles away at her previous home by neighbors, which placed R37 at likelihood for serious harm or death. The IJ began on 8/30/25, when R37 exited the building without staff awareness. An unknown culinary staff had witnessed R37 outside and informed registered nurse (RN)-A who searched and was unable to find R37. The facility was contacted by family member (FM)-A who informed them R37 was found approximately 4.5 miles away without her walker, by R37's previous neighbors after missing for approximately 2.5 hours. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure an elopement was reported to the state agency (SA), within 24 hours for 1 of 1 resident (R37) reviewed for elopement.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was coded accurately for 2 of 3 residents (R7, R56) reviewed for MDS accuracy.

Inspectors wroteBased on observation, interview and document review, the facility failed to develop a care plan which included resident goals and desired outcomes, care and services provided to attain the highest practicable level of wellbeing, and action taken by the facility to educate the resident regarding alternatives and consequences for 1 of 1 resident (R56) who refused medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise a care plan to reflect accurate status when care needs changed for 1 of 19 residents (R12) in the sample.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure pressure ulcer interventions were in place for 1 of 1 residents (R12) reviewed for pressure ulcers (PU).

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R3) received appropriate nutrition assessment and support who was at risk for weight loss and dehydration, and was reviewed for dialysis.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide appropriate monitoring of dialysis access site for 1 of 1 resident (R3) reviewed for dialysis care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure medical records contained accurate documentation for 2 of 2 residents (R3, R12) reviewed for medical record accuracy.

Inspectors wroteBased on interview and document review, the facility failed to ensure 2 of 5 residents (R12, R27) were offered and/or provided updated vaccination for pneumococcal disease, in accordance with Centers for Disease Control (CDC).

Inspectors wroteBased on interview and document review the facility failed to identify the indication for the administration of narcotic medications and failed to ensure non-pharmacological interventions were attempted/offered and documented prior to the administration of as needed (PRN) narcotic medications for 1 of 3 residents (R3) reviewed for pain.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteR3 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteUpon 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.

Inspectors wroteUpon 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide bathing preferences for 1 of 3 residents (R74) reviewed for choices.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.