The Estates At St Louis Park Llc

F-F880 - WASH MACHINE

During observation of laundry room tour on 6/12/24 at 9:08 a.m., a one-page document was observed hanging on a bulletin board by the entryway door, titled Any Shift Laundry Routine. The document provided guidelines on what should be done throughout shift indicating the start and end of shift. The start of shift indicated Load Dryers. At the end of shift, it indicated Load Washers .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 45 245148 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245148 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Estates at St Louis Park LLC 3201 Virginia Avenue South Saint Louis Park, MN 55426

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 6/12/24 at 9:10 a.m., laundry aide (LA)-A and regional district manager (RDM) present during laundry room tour. LA-A verified they worked full-time in laundry services and were familiar with the job. LA-A and Level of Harm - Minimal harm or RDM verified the document titled Any shift laundry routine was up-to date with expectations. LA-A verified potential for actual harm that prior to the end of their shift, they start with wash machines with a load of laundry. LA-A verified the laundry sits in the wash machine through the evening shift and night shift until the next day when staff from Residents Affected - Some the laundry department come in to start their shift. LA-A verified when they start their shift in the morning,

they take the laundry from the wash machine, that was started at the end of their shift the day prior and put it

in the dry machine.

On 6/12/24 at 9:13 a.m., RDM verified that she oversees the department and was covering as the manager was out. When asked about leaving laundry in the wash machine overnight, RDM stated, We are not supposed to do that anymore, we were told that last year. RDM stated she didn't realize it hadn't been updated and would get it corrected. RDM stated leaving wash in the wash machine overnight is of concern because it could grow bacteria and things on it.

On 6/12/24 at 9:38 a.m., administrator stated laundry shouldn't be wet in the wash machine overnight due to potential bacteria growth.

6/12/24 at 1:43 p.m., RDM stated staff working were provided education regarding not leaving laundry in wash machines overnight, an updated laundry routine was hung. RDM stated the remaining laundry staff, and the manager will be in-services upon their return.

A facility policy on wet linens/wash machine relating to infection control was requested and not received.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 45 245148 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245148 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Estates at St Louis Park LLC 3201 Virginia Avenue South Saint Louis Park, MN 55426

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49339 potential for actual harm Based on interview and document review, the facility failed to implement the current standards of Residents Affected - Few vaccinations regarding pneumonia for 1 of 5 residents (Resident R17) over [AGE] years old whose vaccinations histories were reviewed.

Findings include:

A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old.

Resident R17's facility Immunization Record, print date 6/13/24, indicated he was [AGE] years old. The record indicated he received PPSV23 on 1/31/2013 followed by the PCV-13 on 10/4/2016. The immunization record lacked evidence of other pneumococcal immunizations offered, refused, or completed.

Resident R17's Care Conference Form, dated 5/8/24, summarizes a quarterly care conference. The form has a section to address immunizations: Section H: Immunizations (i.e., pneumococcal, influenza, Covid series) was not completed. The section lacked evidence of completion.

On 6/13/2024 at 10:14 a.m., director of nursing verified that she is the infection preventionist for the facility.

She verified that she oversees the immunizations. DON indicated the nurse managers review and determine what immunizations residents need and they will work with their power of attorney (POA) or guardian if they are not able to make their own decisions. DON verified Resident R17's pneumococcal immunizations as listed above and would be eligible for the PCV20. DON stated she followed up with the nurse manager on the floor who has called Resident R17's guardian, received approval for administration of PCV20. DON verified Resident R17's guardian was updated regarding eligibility of immunization on 6/13/24, stated the nurse manager lost her list of who needs

it but did call now. DON indicated it is important to offer residents immunizations they are eligible for.

A facility policy titled Pneumococcal Policy, dated 2/24, was provided. Policy indicated to offer all residents

the pneumococcal vaccines to aid in the prevention of pneumococcal/pneumonia infections by following the Advisory Committee on Immunization Practices (ACIP), Centers for Disease Control (CDC) and/or the state Department of Health.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 45 245148 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245148 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Estates at St Louis Park LLC 3201 Virginia Avenue South Saint Louis Park, MN 55426

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm 33925

Residents Affected - Few Based 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 (Resident R92) reviewed whose closet door was broken with exposed nails present.

Findings include:

A Vulnerable Adult Maltreatment Report, dated 7/2023, identified a general concern about the care center which included, . [it] needs major repairs and there are multiple things that are broken.

Resident R92's quarterly Minimum Data Set (MDS)assessment, dated 3/21/24, identified Resident R92 had intact cognition and demonstrated no delusional thinking.

On 6/10/24 at 1:46 p.m., Resident R92 was observed lying in bed while in his room. The room had an off-white colored closet with double doors which opened towards the foot of Resident R92's bed. However, the closet door was in disrepair with the door and attached frame being pulled away from the wall several inches exposing multiple construction nails with the bevel-end open to the outside (i.e., room). The door was loose to touch and the closet' interior was visible through the exposed gap between the frame and wall. The closet had visible clothing and CPAP (low pressure air machine used to help breathing) supplies inside. Resident R92 was interviewed and stated the closet was broken and had been for a couple weeks. Resident R92 stated he had asked staff to complete a 'work-order' for it to get it fixed, however, no action had been taken on it yet. Resident R92 stated, I don't think anybody put in a work order [despite being asked]. Resident R92 stated he wanted it fixed and was fearful the door would eventually fall off and onto his bed with him in it.

Two days later, on 6/12/24 at 9:02 a.m., the closet door was again observed and remain in disrepair with exposed nails. When interviewed on 6/12/24 at 9:41 a.m., nursing assistant (NA)-D stated Resident R92 needed 100% total help with cares and was mostly bed-bound. NA-D observed Resident R92's closet door and stated aloud, It's coming apart! NA-D stated they were unaware the closet was in disrepair and attempted to move the closet door when it then fell completely off the wall. NA-D stated, It came out. Resident R92 was present in his bed and again reiterated it had been in such condition for sure, over a week now. NA-D stated they were unsure if maintenance was aware of it or not and expressed they would get it entered in TELS [software] right away to be addressed.

On 6/12/24 at 12:33 p.m., the director of maintenance (DOM) was interviewed. DOM explained if staff notice items in disrepair then a TELS work-order should be place so the maintenance staff can be updated about it. DOM stated they had just been made aware of Resident R92's closet door being in disrepair (during the survey) as nobody put it on there [TELS]. DOM verified none of the staff had completed a TELS and, as a result, nobody from maintenance was aware it was in disrepair adding the closet door was pulled from the frame itself and needed multiple staff members to help repair it just prior. DOM stated Resident R92 was mostly bed-bound so it was likely someone else, likely staff, who broke the door adding, It had to be somebody with quite some force. DOM reiterated it should have been reported to them for repair adding, I don't know how somebody [would] not notice that. DOM added, It could fall on somebody, and, It's a safety thing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 45 245148 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245148 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Estates at St Louis Park LLC 3201 Virginia Avenue South Saint Louis Park, MN 55426

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 A Work Order #16293, dated 6/12/24, identified Resident R92's room along with a heading, Cloet [sic] door broken. A timeline was present which identified the tracking through the TELS system; this outlined it had been created Level of Harm - Minimal harm or on 6/12/24. There was no further evidence provided to demonstrate the broken closet door had been notified potential for actual harm or addressed prior to 6/12/24.

Residents Affected - Few A facility' policy on maintenance requests or repairs was not received.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 45 245148