R74 told inspectors on June 24 that he had not had a shower since admission to the facility. He had an odor and stated he hadn't had a bath in weeks. His medical diagnosis form showed sepsis, rhabdomyolysis, encephalopathy, blindness, and personality disorder.
"R74 stated he had a sponge bath twice but stated they don't give him a shower," inspectors wrote.
The resident's family member received a voicemail about a week before the inspection saying R74 would receive a bath either that evening or the following morning. But no bath came.
Staff had placed R74 on a Sunday morning bath schedule according to a form hanging on the nursing station wall. His care plan indicated weekly baths but didn't specify the type or time.
When nursing assistant NA-C offered to get R74 up on June 26, he declined because he didn't like getting up at 7:00 or 8:00 a.m. but still wanted to have a bath.
The director of social services said she wouldn't disturb R74 if he was sleeping because he gets agitated and sometimes refuses to get out of bed or participate in therapy.
R74's clinical records showed a physician order for weekly skin inspections during bath time every Sunday at 8:00 a.m. But inspectors found only one Weekly Skin Inspection form dated June 9 showing he received a bed bath. His progress notes from May 24 through June 25 contained no documentation that baths were provided or refused.
Licensed practical nurse LPN-E acknowledged seeing R74's dirty nails on June 24 and offering to trim them but failed to document it. He admitted the showers should be documented and said he was aware R74 had told him he hadn't had a shower.
The facility's director of nursing said staff should check resident preferences after admission and update care plans accordingly. She expected the resident assessment to be completed but didn't know why it wasn't.
A separate resident faced dangerous gaps in wound care and oxygen therapy.
R48 had multiple pressure ulcers including a left gluteus wound that required daily foam dressing changes. But wound care provider orders from June 12 never made it into the facility's electronic medical record.
On June 25, licensed practical nurse LPN-A assessed R48's left gluteus pressure ulcer dressing, which had a date of June 25 written on it. She told inspectors she couldn't find orders in the system for dressing changes and simply replaced what was already there.
The next day, nurse practitioner NP-A removed a wet foam dressing from the same wound during weekly rounds. She changed the orders to include calcium alginate for the heavily draining wound but acknowledged the original foam dressing orders should have been entered into the system after her June 12 visit.
"NP-A stated she expected her orders to be entered into the facility EMR to ensure continuity of care and to help prevent infections," the report states.
The director of nursing confirmed she could not find orders for the left gluteus pressure ulcer dressing changes and said it was expected that the nurse attending wound rounds would enter orders into the system.
Another resident with chronic obstructive pulmonary disease received oxygen therapy for weeks without proper orders or monitoring.
R50's oxygen saturations dropped to 87% on June 4, prompting a nurse practitioner to order oxygen at two liters per minute to keep saturations above 88%. But the verbal order was never transcribed into the electronic medical record.
On June 24, inspectors found R50 in bed with labored breathing evidenced by nose flaring and grunting. Her nasal cannula was not in her nose but lying on the bed mattress. When awakened, she asked for help placing it on.
The next day, inspectors found the oxygen concentrator not running and the nasal cannula on the floor. R50 asked where her oxygen tubing was and requested it be turned on. When registered nurse RN-B entered the room, he picked up the tubing from the floor, got new equipment, turned on the concentrator and placed the cannula in R50's nose without completing any respiratory assessment.
Licensed practical nurse LPN-B said he had seen oxygen in R50's room for weeks but never checked if an order was in place. He acknowledged that if a resident required oxygen, an order needed to be in place and monitoring should be completed.
RN-B later found the written provider order dated June 4 that had never been entered into the electronic system. He admitted he hadn't checked oxygen saturations before implementing treatment as the provider ordered.
R50's care plan from January identified potential for respiratory distress related to COPD and directed staff to monitor for signs of acute respiratory insufficiency. But her medication records showed no administration of her prescribed albuterol inhaler from April through June.
The facility also failed to follow infection control protocols during high-risk procedures.
R48 required enhanced barrier precautions due to tube feeding and chronic pressure wounds. Her room door displayed a sign directing staff to wear gloves and gowns for high contact care including feeding tube procedures.
On June 25, LPN-A entered R48's room for tube feeding care wearing only gloves, not the required gown. She undid the abdominal binder, flushed the feeding tube with water, refastened the binder, changed gloves, filled the water flush bag, and connected the feeding equipment.
When questioned, LPN-A said someone she couldn't remember told her she wasn't required to follow enhanced barrier precautions during tube feeding care, despite the door signage and electronic medical record orders.
A resident with multiple falls continued experiencing safety failures.
R19 had severe cognitive impairment, seizures, and a history of recent hospital admissions including subdural bleeding after a fall. He fell on June 12 and again on June 15, prompting staff to add a floor mat intervention to his care plan.
On June 24, inspectors observed R19 trying to get out of bed while incontinent of stool. His care sheet indicated he should have a mat on the floor next to his bed, but no mat was present. Nursing assistant NA-F confirmed the care plan required a floor mat but verified none was on the floor.
That same day, the interdisciplinary team met and decided to discontinue the floor mat, implementing instead safety checks between 6:00 and 6:30 a.m. But R19's medical record contained no documentation of this change at the time of the inspection.
Licensed practical nurse manager LPN-E said they discussed the mat the previous day and thought the fall was more of a toileting issue. The director of nursing said they changed his intervention that morning and expected staff to follow care plans.
Another resident lost mobility function when staff failed to implement a prescribed walking program.
R47 had a right leg amputation and used a prosthetic device. Physical therapy discharge notes from December 2023 recommended a restorative nursing program for ambulation to maintain walking ability after formal therapy ended.
R47's care plan directed staff to help him walk 40-120 feet daily using a four-wheel walker, gait belt, and prosthetic leg. But R47 told inspectors on June 24 and 25 that he had not used his prosthetic lately due to pain and hadn't walked for four weeks.
Staff treatment records showed signatures indicating the walking program was completed, but multiple staff members said they hadn't seen R47 walking recently. The activities director couldn't remember the last time R47 had walked.
On June 25, an interdisciplinary team note stated R47 was not appropriate for the restorative program due to refusal to participate and complaints about prosthetic fit. The team referred him back to physical therapy.
Physical therapist PT-B said R47 walked 50 feet the day after the team meeting with the prosthetic fitting well and was motivated to participate in the walking program.
The director of nursing said staff should follow orders and attempt several times if residents refuse. Continued refusals should be brought to the interdisciplinary team for follow-up.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Villas At St Paul from 2024-06-27 including all violations, facility responses, and corrective action plans.