Galtier A Villa Center

F-F0300 indicated an interview for daily and activity preferences should be conducted and should continue to

F-F0400, Interview for Daily Preferences, that included: how important is it to you to choose between a tub bath, shower, bed bath, or sponge bath.

Resident R74's Medical Diagnosis form dated 6/27/24 at 9:53 a.m., indicated the following diagnoses: sepsis, rhabdomyolysis (a muscle injury where muscles break down), encephalopathy (a disturbance of brain function), blindness, and personality disorder.

Resident R74's care sheet lacked information when Resident R74 would receive a bath or what type.

Resident R74's care plan saved on 6/27/24 at 12:06 p.m., indicated Resident R74 had a weekly bath as scheduled, but did not indicate the type or time.

Resident R74's Clinical Physician Orders form, indicated the following order:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 23 245340 Department of Health & Human Services Printed: 09/22/2025 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 245340 B. Wing 06/27/2024

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

The Villas at St Paul 445 Galtier Avenue Saint Paul, MN 55103

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 0636 5/17/24, weekly skin inspection by licensed nurse. Complete weekly skin inspection in the electronic medical

record (EMR) one time a day every Sunday at 8:00 a.m., for bath day. Level of Harm - Minimal harm or potential for actual harm A form, Second Floor Bath Schedule, undated, identified resident room numbers under the various days of

the week and additionally were separated into an a.m., or p.m., slot. The bath schedule indicated Resident R74 would Residents Affected - Few receive a bath on Sunday a.m. The form further indicated the nurse assessed skin for every bath or shower and completed a skin assessment and refusals were documented in the EMR. Further, the form indicated the nurse must complete a weekly skin inspection evaluation on bath days.

Resident R74's Clinical Assessment form dated 6/27/24 at 11:42 a.m., in the EMR indicated one Weekly Skin Inspection form dated 6/9/24. No other Weekly Skin Inspection forms were located.

Resident R74's Weekly Skin Inspection form dated 6/9/24 at 9:37 p.m., indicated Resident R74 had a bed bath and it was not necessary to trim Resident R74's fingernails.

Resident R74's Follow Up Question Report from 6/1/24, through 6/27/24, indicated the following:

6/2/24, (Sunday) not applicable for how Resident R74 took a full body bath, shower, sponge bath and transfers in and out of the tub shower.

6/9/24, (Sunday) physical help limited to transfer only for how Resident R74 took a full body bath, shower, or sponge bath and transfers in and out of the tub shower.

6/16/24, (Sunday) no documentation was found under the report.

Resident R74's progress notes were reviewed from 5/24/24, to 6/25/24, and lacked information a bath was provided or if resident refused.

During interview and observation on 6/24/24 between 1:21 p.m., and 1:30 p.m., Resident R74 stated he has not had a shower since he has been at the facility. Resident R74 had an odor and stated he hasn't had a bath in weeks. Resident R74 had black debris under his fingernails that were approximately 1/2 inch long. Resident R74 stated he had a sponge bath twice but stated they don't give him a shower. Resident R74's family member (FM)-A stated she received a voicemail from approximately a week ago Friday and played the voice message that indicated Resident R74 would receive a bath if not that evening, the following morning.

During interview on 6/25/24 at 11:19 a.m., nursing assistant (NA)-C stated residents had a bath schedule and went into the 2nd floor nursing station to show the Second Floor Bath Schedule form hanging on the wall. The schedule indicated room [ROOM NUMBER]-1's bath day was on Sunday a.m. shift.

During interview on 6/26/24 at 8:38 a.m., NA-C stated she offered to get Resident R74 up, but Resident R74 was just going to hang out in bed.

During interview on 6/26/24 at 8:55 a.m., Resident R74 stated NA-C asked if there was anything she could do for him and he told her no and stated he did not like to get up at 7:00 a.m., or 8:00 a.m., but still wanted to have a bath.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 23 245340 Department of Health & Human Services Printed: 09/22/2025 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 245340 B. Wing 06/27/2024

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

The Villas at St Paul 445 Galtier Avenue Saint Paul, MN 55103

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 0636 During interview on 6/26/24 at 9:53 a.m., the director of social services (DSS)-A stated if Resident R74 was sleeping

she wouldn't disturb Resident R74 because he gets agitated and at times refused to get out of bed and sit at the table Level of Harm - Minimal harm or and at times would refuse therapy at times as well. potential for actual harm

During interview on 6/26/24 at 10:27 a.m., certified occupational therapist assistant (COTA)-A stated Resident R74 Residents Affected - Few refused therapy once because his sister was visiting, otherwise participated in therapy.

During interview on 6/26/24 at 1:56 p.m., physical therapist (PT)-B stated Resident R74 didn't sleep well this week and was not motivated so therapy needed to come back a few times to convince Resident R74 to do stuff.

During observation on 6/26/24 at 2:00 p.m., Resident R74 was up in the wheelchair and had moved to room [ROOM NUMBER]-2.

During interview on 6/27/24 at 9:27 a.m., the director of reimbursement (DR) stated she scheduled the MDS and stated registered nurse (RN)-D completed all the sections of the MDS except C, D, E, F, K, and Q. DR stated activities completed section F (preferences) of the MDS. DR further stated section F was completed to incorporate a resident's preferences in the plan of care and stated it was important to have a personalized person centered plan of care and expected section F to be completed.

During interview on 6/27/24 at 10:45 a.m., RN-D stated she worked remotely and had been helping out to complete the MDS sections and make sure the MDS got completed and stated if a section was not completed, she had to go in and finish it and stated if a section was not done, she would go in and dash the answers to get the MDS completed and stated section F hasn't been getting completed consistently, but was not sure why and stated it was important to complete to know what a resident's preferences were and stated residents could refuse interviews, but stated staff would follow the resident assessment instrument (RAI) manual instructions for completing section F.

During interview and observation on 6/27/24 at 11:20 a.m., licensed practical nurse and nurse manager (LPN)-E stated Resident R74 was in room [ROOM NUMBER]-1 and moved to 205-2 and stated Resident R74 preferred to go to

the shower and liked to sleep in and was adamant about that and did not like to get up in the morning. LPN-E viewed section F of the admission MDS dated [DATE REDACTED], and stated the MDS created a structure for a care plan for them to follow and stated they lost their MDS nurse and stated Resident R74's bath day was on Sunday a.m.'s according to the bath schedule and stated that would change to Wednesday evenings after viewing the Second Floor Bath Schedule that indicated Resident R74's new room number was located in the p.m., slot for a bath. LPN-E further stated they covered things in care conferences so they knew what Resident R74 liked. LPN-E stated baths were documented under the Forms tab in the EMR in a Weekly Skin Inspection form. LPN-E viewed Resident R74's Forms tab and located one Weekly Skin Inspection form dated 6/9/24, that indicated Resident R74 had a bed bath and verified he did not see any additional Weekly Skin Inspection forms and verified again they were documented in the EMR under Forms and stated if Resident R74 refused, a progress note was documented. Further, LPN-E stated Resident R74 could provide information accurately and stated Resident R74's admission assessment on 5/17/24, indicated he wanted a sponge bath, but stated Resident R74 was more lethargic when he first arrived and stated he would have to dig into locating documentation on baths and stated he was aware Resident R74 has told him he hasn't had a shower and stated the showers should be documented and added he saw Resident R74's dirty nails on 6/24/24, and offered to trim them and should have documented that, but did not. Additionally, LPN-E viewed Resident R74's progress notes that lacked any documentation of refusals.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 23 245340 Department of Health & Human Services Printed: 09/22/2025 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 245340 B. Wing 06/27/2024

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

The Villas at St Paul 445 Galtier Avenue Saint Paul, MN 55103

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 0636 During interview on 6/27/24 at 11:44 a.m., the director of nursing (DON) stated after admission, they check if

a resident wants a shower and what time of day and whatever preferences they have they update the care Level of Harm - Minimal harm or plan and would have expected the MDS to be completed and did not know why it was not and stated it was potential for actual harm very important to know what a resident's preferences were and stated they did not have a policy regarding

the MDS, but followed the RAI manual. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 23 245340 Department of Health & Human Services Printed: 09/22/2025 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 245340 B. Wing 06/27/2024

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

The Villas at St Paul 445 Galtier Avenue Saint Paul, MN 55103

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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42579 potential for actual harm Based on observation, interview, and document review, the facility failed to ensure the wound care provider's Residents Affected - Few treatment orders were transcribed into the medical record to ensure continuity of care for 1 of 2 (Resident R48) residents reviewed for pressure ulcers.

Findings include:

Resident R48's quarterly Minimum Data Set (MDS) dated [DATE REDACTED], identified severely impaired cognition and no rejection of care or behaviors. Diagnoses included stroke, renal insufficiency, diabetes, aphasia (inability to speak), and malnutrition. Total assistance of two staff was required for bed mobility and transfers; and two stage three pressure ulcers, one unstageable pressure ulcer and diabetic foot ulcer were present.

Resident R48's significant change Care Area Assessment (CAA) dated 3/22/24, triggered and identified Resident R48 was at risk for developing a pressure injury and other non-pressure related skin concerns. Nursing was directed to continue to monitor for changes in condition, update provider on concerns, complete a weekly skin check and proceed to care plan.

Resident R48's pressure ulcer care plan dated 6/26/24, identified a sacral pressure ulcer, two toe pressure ulcers, one diabetic foot ulcer and a left gluteus (muscles in the buttock/hip area) pressure ulcer. The wound care providers followed due to alterations in skin integrity, and the goal was to remain infection free. Staff were directed to monitor for skin breakdown, for signs/symptoms of infection and to report signs/symptoms to the providers. The care plan lacked direction for wound care dressing change orders.

Resident R48's wound care provider orders dated 5/29/24, and 6/5/24, lacked orders or assessment of the left gluteus pressure ulcer. Orders dated 6/12/24, identified a stable stage two left hip [gluteus] wound. Apply foam daily and follow wound care team weekly.

Resident R48's electronic medical record (EMR) orders dated 6/12/24 through 6/26/24, lacked documentation of dressing change orders for the left gluteus pressure ulcer.

Resident R48's medication administration record (MAR) and treatment administration record (TAR) dated 6/12/24 through 6/26/24 lacked documentation of the above ordered dressing changes to the left gluteus pressure ulcer.

During an observation on 6/25/24 at 12:44 p.m., licensed practical nurse (LPN)-A assessed the placement of Resident R48's left gluteus pressure ulcer dressing which was had a written date on it of 6/25/24. LPN-A stated wound care orders would be found in the EMR, she reviewed PCC and stated there was not an order in the EMR to change the dressing and she replaced the dressing she saw was previously in place.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 23 245340 Department of Health & Human Services Printed: 09/22/2025 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 245340 B. Wing 06/27/2024

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

The Villas at St Paul 445 Galtier Avenue Saint Paul, MN 55103

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 0686 During an observation and interview on 6/26/24 at 1:01 p.m., nurse practitioner (NP)-A, an unidentified wound care provider, and LPN-D entered Resident R48's room for weekly wound care provider rounds. NP-A removed Level of Harm - Minimal harm or a wet, foam dressing from Resident R48's left gluteus pressure ulcer. NP-A stated the wound was wet with drainage potential for actual harm this week, so she was going to change the wound care orders to include calcium alginate (fiber used to treat moderate to heavily draining wounds) and a foam dressing. LPN-D and surveyor reviewed the EMR to find Residents Affected - Few no current orders for left gluteus dressing changes. NP-A stated the dressing changes should be in the EMR for the facility nurses to follow.

During an interview on 6/26/24 at 2:49 p.m., the director of nursing (DON) stated she could not find orders for

the left gluteus pressure ulcer dressing changes in the EMR, and it was expected the nurse attending wound rounds would enter the orders into the EMR.

During a follow up interview on 6/26/24 at 3:38 p.m., with NP-A, the DON, facility administrator, regional nurse consultant (RNC), and an unidentified regional consultant, NP-A reviewed her wound care notes and verified the foam dressing orders should have been entered into the EMR following her 6/12/24, wound care rounds; and the left hip phraseology meant left gluteus. NP-A stated she expected her orders to be entered into the facility EMR to ensure continuity of care and to help prevent infections. NP-A stated she included the same orders as 6/12/24, for foam dressing change daily; in her 6/19/24, wound care orders (notes were requested and not provided) and on 6/26/24 wound care orders, she changed the orders to a foam dressing with calcium alginate (notes were requested and not provided). NP-A stated she did not believe the lack of dressing change orders, or the ability to review documentation if the dressing changes were completed as ordered contributed to Resident R48's wound becoming a wet pressure ulcer.

The facility policy titled Skin Assessment and Wound Management dated 3/2024, identified when a pressure ulcer was identified the provider would be notified and treatment ordered, including updating the care plan with interventions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 23 245340 Department of Health & Human Services Printed: 09/22/2025 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 245340 B. Wing 06/27/2024

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

The Villas at St Paul 445 Galtier Avenue Saint Paul, MN 55103

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 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50762

Residents Affected - Few Based on observation, interview, and document review, the facility failed to ensure restorative nursing program (RNP) was completed for 1 of 1 resident (Resident R47) reviewed for mobility.

Findings include:

Resident R47's face sheet printed 6/27/23 listed the pertinent diagnoses of peripheral vascular disease, muscle weakness, difficulty in walking, acquired absence of right leg above knee, and chronic pain syndrome.

Resident R47's quarterly Minimum Data Set, dated dated dated [DATE REDACTED], indicated Resident R47 was cognitively intact, no rejection of care noted, lower extremity impairment on one side, wheelchair use, and no restorative nursing program.

Resident R47's Physical Therapy Discharge Summary dated 12/21/23, indicated Resident R47 to have a RNP regarding ambulation after discharge from physical therapy to maintain and increase ease with ambulation.

Resident R47's care plan dated 5/23/24 indicated the resident has, an ADL Self Care Performance Deficit r/t Amputation, Impaired balance, Limited Mobility, Pain. Resident has a right leg prosthesis. The plan directed staff to ambulate the resident with an assist of x1 for 40-120 feet on the unit using a four-wheel walker, gait belt, and wheelchair to follow once daily and to also ensure the prosthetic is on properly.

When interviewed on 6/24/24 at 12:09 p.m., Resident R47 stated they have not used their prosthetic leg lately, as it was causing pain.

When interviewed on 6/25/24 at 12:00 p.m., Resident R47 stated they did not use the prosthetic leg yesterday and has not walked for the past four weeks. Resident R47 stated wanted to walk.

When interviewed on 6/25/24 at 1:08 p.m., nursing assistant (NA)-D stated Resident R47 sometimes does not like to wear the prosthesis.

When interviewed on 6/25/24 at 1:50 p.m., physical therapist (PT)-B stated that Resident R47 had completed gait training and was discontinued from the physical therapy program at the end of December of 2023. At that time, the resident was able to walk 90 feet with the prosthesis while using a front wheeled walker, wheelchair follow, and stand by assist. The physical therapy team conducted and completed training with several nursing staff members regarding Resident R47's therapy plan and it was ended with a RNP plan in place. PT-B stated that there was no end date to this RNP and expected it to be continued unless otherwise notified. PT-B was unaware of any concerns regarding Resident R47's prosthesis.

When interviewed on 6/25/24 at 2:49 p.m., registered nurse (RN)-B who was also the nurse manager verified

the documentation on the treatment administration record (TAR), stated that it would mean the order was completed, and that most of the time it was the nurse to monitor the identified task. RN-B stated not seeing Resident R47 walking with the prosthesis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 23 245340 Department of Health & Human Services Printed: 09/22/2025 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 245340 B. Wing 06/27/2024

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

The Villas at St Paul 445 Galtier Avenue Saint Paul, MN 55103

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 0688 Resident R47's physician order dated 12/25/23, instructed staff to ambulate Resident R47 with staff assist for 40-120 feet on unit using four-wheel walker, gait belt, and wheelchair to follow once daily. Staff to also ensure that the Level of Harm - Minimal harm or resident has the prosthesis on properly with ambulation. This order was discontinued on 6/25/24. potential for actual harm Resident R47's TAR indicated by staff signatures showed the RNP order was being completed; however, an Residents Affected - Few interdisciplinary team (IDT) note dated 6/25/24 at 4:24 p.m. identified IDT met and discussed resident's need for nursing restorative program and determined that resident is not appropriate for program due to refusal to participate. Resident complains of pain with prosthetics fitting. Referral for therapeutic (PT + OT) evaluation to treat active. Resident has a scheduled appointment with pain clinic to eval.

When interviewed on 6/26/24 at 9:24 a.m., PT-B stated Resident R47 walked yesterday with prosthetic after the IDT meeting. Resident R47 was able to walk 50 feet with stand by assist, wheelchair follow, while using front wheeled walker with prosthesis fitting well. PT-B stated Resident R47 was motivated to participate with RNP for ambulation.

When interviewed on 6/26/24 at 09:42 a.m., RN-B stated if there was an order for staff to complete that they should follow the order. If the resident either refuses or was independent with the order that staff would chart that appropriately.

When interviewed on 6/26/24 at 10:07 a.m., registered nurse (RN)-A stated although they had signed off on Resident R47's TAR, they did not recall seeing Resident R47 walking on 6/24/24.

When interviewed on 6/26/24 at 10:18 a.m., activities director stated not seeing Resident R47 walking recently and did not remember the last time Resident R47 had walked.

When interviewed on 6/27/24 at 11:29 a.m., the director of nursing stated that staff should follow the orders and walk the resident. If the resident refuses, staff should attempt several times. This information should be relayed to the nurse manager and then brought to the interdisciplinary team (IDT) for follow up. If this refusal continues, the IDT will discontinue the order and follow up with therapy and follow their recommendations.

A Restorative Nursing Program policy was requested, none provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 23 245340 Department of Health & Human Services Printed: 09/22/2025 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 245340 B. Wing 06/27/2024

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

The Villas at St Paul 445 Galtier Avenue Saint Paul, MN 55103

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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46885

Residents Affected - Few Based on observation, interview, and document review, the facility failed to ensure 1 of 2 residents (Resident R19) with repeated falls had implemented interventions to promote safety and reduce the risk of falls.

Findings include:

Resident R19's Optional State Assessment (OSA) dated 5/30/24, indicated severe cognitive impairment, did not have behaviors, did not reject care, and required extensive assist for bed mobility, transfers, and toileting.

Resident R19's admission Minimum Data Set (MDS) dated [DATE REDACTED], indicated Resident R19 was frequently incontinent of bowel, had an indwelling catheter, and was not on a toileting program, did not fall in the last month prior to admission, did not fall in the last 2 to 6 months prior to admission, and had not fallen since admission.

Resident R19's care area assessment (CAA) summary dated 5/30/24, indicated falls was not triggered.

Resident R19's Medical Diagnosis form indicated the following diagnoses: peritoneal abscess, traumatic subdural hemorrhage without loss of consciousness, seizures, anemia, chronic kidney disease, acute pyelonephritis, and diabetes mellitus.

Resident R19's hospital physician notes dated 5/24/24, indicated Resident R19 had multiple recent hospital admissions including: 2/27/24, for sepsis secondary to acute cholecystitis, 5/1/24, to 5/11/24, subdural (bleeding between the skull and surface of the brain) after a fall, a readmission on 5/11/24 with an abdominal abscess.

Resident R19's history of present illness (HPI) dated 6/20/24, indicated Resident R19 was frail, had recurrent falls, seizure disorder, and was at high risk for delirium.

Resident R19's care plan saved on 6/24/24 at 2:29 p.m., indicated Resident R19 was at risk for falls related to impaired mobility, safety awareness, and unsteady gait and had the following interventions in place, floor mat next to the bed, and a low bed.

Resident R19's care sheet provided on 6/24/24, at 12:48 p.m., by nursing assistant (NA)-E indicated Resident R19 required a floor mat next to the bed.

Resident R19's progress notes dated 6/12/24 at 2:00 p.m., indicated Resident R19 fell during the night shift and was alert and oriented as usual with no change in level of consciousness.

Resident R19's progress notes dated 6/13/24 at 1:48 p.m., indicated the interdisciplinary team (IDT) met and reviewed Resident R19's fall 6/13/24, and Resident R19 had a bump on his head, the bed was at the lowest position and Resident R19 had a history of seizures; and an intervention for a floor mat was added to prevent further injury.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 23 245340 Department of Health & Human Services Printed: 09/22/2025 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 245340 B. Wing 06/27/2024

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

The Villas at St Paul 445 Galtier Avenue Saint Paul, MN 55103

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 0689 Resident R19's progress notes dated 6/15/24 at 9:30 a.m., indicated Resident R19 was found lying on the floor next to his bed and further was speaking in Spanish and staff could not understand how or why Resident R19 fell . Level of Harm - Minimal harm or potential for actual harm Resident R19's progress notes dated 6/15/24 at 12:0 p.m., indicated Resident R19 was sent to the hospital.

Residents Affected - Few Resident R19's progress notes dated 6/17/24 at 2:12 p.m., indicated IDT discussed Resident R19's fall on 6/15/24, and Resident R19 had

an elevated white blood cell count and the fall was due to a change in condition.

Resident R19's progress notes dated 6/24/24 at 6:23 p.m., indicated IDT met to discuss Resident R19's floor mat and was hospitalized the week prior for a urinary tract infection. The note further indicated Resident R19 had a fall on 6/15/24, and Resident R19 was attempting to go to the toilet that morning before breakfast and the floor mat has been discontinued at this time. Further, the note indicated staff were to complete safety checks between 6:00 a.m., and 6:30 a.m., to assess for toileting, safety, and any other needs.

Resident R19's Fall Review Evaluation form dated 5/24/24, and locked on 6/4/24, indicated, Resident R19 had no history of falling, took medications that may contribute to falls, was frequently incontinent, had agitated behavior, was confined to a chair and disoriented, could not independently come to a standing position. The form lacked any summary or interventions.

Resident R19's Fall Review Evaluation form dated 6/2024, indicated Resident R19 was on medications that contributed to falls, was incontinent, used a cane, walker, or etc. The documentation lacked any summary or interventions.

Resident R19's risk management report dated 6/12/24, indicated Resident R19 was found on the floor next to the bed lying on his right side and Resident R19 was unable to provide a description. Under the section, Immediate Action Taken, indicated Resident R19 was assisted back to bed with a mechanical lift and Resident R19 had a history of seizures and orders were placed for seizure activity; intervention for adding a floor mat to prevent further injury. Under the section, Mobility, indicated Resident R19 was non ambulatory, and there were no predisposing environmental factors. Further, the form identified Resident R19 had an unsteady gait and was confused. Under the heading, Notes, indicated IDT met and reviewed the fall and Resident R19 had a history of seizures and orders placed for seizure activity and intervention for adding floor mat to prevent further injury and the care plan was updated.

Resident R19's risk management report dated 6/15/24, indicated Resident R19 was calling for help and staff found Resident R19 lying on

the floor next to his bed, was speaking Spanish and could not understand why or how Resident R19 fell . Under the section, Mobility, indicated Resident R19 was not ambulatory, additionally, the report indicated Resident R19 was incontinent and had a history of falls under the section, Predisposing Physiological Factors, and under the heading, Predisposing Situation Factors, indicated Resident R19 rolled out of bed. Additionally, the note indicated IDT discussed Resident R19's fall on 6/15/24, and a lab was completed the evening prior that revealed an elevated white blood cell count and the fall was due to a change in condition and Resident R19 was in the hospital.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 23 245340 Department of Health & Human Services Printed: 09/22/2025 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 245340 B. Wing 06/27/2024

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

The Villas at St Paul 445 Galtier Avenue Saint Paul, MN 55103

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 0689 During interview and observation on 6/24/24 between 2:17 p.m., and 2:21 p.m., Resident R19 was in a gown and trying to get out of bed, stating he had to go to the bathroom. Resident R19 was incontinent of stool and was Level of Harm - Minimal harm or positioned on his left side with a pillow under him. At 2:18 p.m., nursing assistant (NA)-E was alerted Resident R19 potential for actual harm was trying to get out of bed and came into Resident R19's room. Resident R19's care sheet indicated Resident R19 was supposed to have a mat on the floor next to the bed. NA-F verified Resident R19's care sheet indicated Resident R19 was to have a mat on Residents Affected - Few the floor. Resident R19's care plan was viewed and indicated Resident R19 was to have a mat on the floor and a low bed and NA-F verified there was no mat on the floor.

During interview on 6/24/24 at 2:39 p.m., licensed practical nurse manager (LPN)-E stated Resident R19 fell a couple of weeks ago and needed the floor mat to be down and expected staff to follow the care plans.

During interview on 6/25/24 at 1:25 p.m., LPN-E later stated they spoke about the mat the day prior and thought the fall was more of a toileting issue that morning and stated if the residents don't need to use the mat, they are discontinued and stated they discussed checking Resident R19 in the morning and stated he was not at

the IDT meeting.

During interview on 6/25/24, at 1:52 p.m., the director of nursing (DON) stated Resident R19 had the mat on the floor because Resident R19 was trying to self transfer and had fallen due to a change in condition and stated Resident R19 went to

the hospital with a urinary tract infection and stated they changed his intervention yesterday a.m. The DON stated when they have IDT, they discussed it in the morning and then staff are updated on changes and stated they communicate with staff and the nurse manager communicates with staff and further stated she would expect staff to follow the care plan.

During observation on 6/26/24 at 8:18 a.m., Resident R19 was in bed sleeping and his bed was all the way down to

the floor. There was no wheelchair located next to the bed and no mat was on the floor.

During interview on 6/26/24 at 12:42 p.m., nurse practitioner (NP)-B stated she was notified of falls via email or phone call and stated she was not not updated on any intervention changes with the mat until the DON updated her today.

A policy, Fall Prevention and Management, indicated the purpose of the protocol was to identify residents at risk for falls, implement fall prevention interventions, provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Nursing staff will complete a Fall Risk Evaluation to identify and document resident's risk factors for falls upon admission, annually, with a significant change in condition and as needed. Facility staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant.

A Daily Huddle Notes form was later provided dated 6/24/24, no time identified, that indicated Resident R19's floor mat would be removed and staff would complete safety checks around 6:00 a.m., to 6:30 a.m., to make sure Resident R19 was comfortable and dry, however there was no information in Resident R19's medical record at the time of the

observation on 6/24/24, to indicate the floor mat was discontinued.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 23 245340 Department of Health & Human Services Printed: 09/22/2025 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 245340 B. Wing 06/27/2024

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

The Villas at St Paul 445 Galtier Avenue Saint Paul, MN 55103

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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42579 potential for actual harm Based on observation, interview, and document review, the facility failed to ensure respiratory status was Residents Affected - Few monitored and assessed on an ongoing basis, and that respiratory medications were provided as indicated for 1 of 1 resident (Resident R50) reviewed with newly prescribed oxygen use.

Findings include:

Resident R50's significant change Minimum Data Set (MDS) dated [DATE REDACTED], identified severely impaired cognition, no rejection of care; diagnoses of psychosis, irregular heart rate, high blood pressure, and chronic obstructive pulmonary disease (COPD/chronic inflammatory lung disease that causes obstructed airflow from the lung). No supplemental oxygen use was identified. Resident R50 required extensive assist with bed mobility and was independent with eating but required set up.

Resident R50's activities of daily living (ADL) care area assessment (CAA) dated 5/8/24, was triggered because the resident required assist with cares and had impaired cognition. Nursing was directed to monitor for changes

in condition, update provider as necessary on concerns if observed, and to proceed with care plan.

Resident R50's care plan dated 1/19/24, lacked interventions for oxygen use. The care plan identified a potential for respiratory distress related to COPD. Interventions included: elevate head of bed to alleviate shortness of breath, position resident with proper body alignment for optimal breathing pattern, give aerosol or bronchodilators as ordered, and monitor and document any side effects and effectiveness. Lastly, Resident R50 should be monitored for signs and symptoms of acute respiratory insufficiency: anxiety, confusion, restlessness, shortness of breath at rest, cyanosis, and somnolence.

Resident R50's physician orders dated 3/17/24, identified: albuterol sulfate inhaler 108 mcg of albuterol sulfate (90 mcg of albuterol base) give two puffs by mouth every six hours as needed (PRN) for wheezing or shortness of breath.

Resident R50's Medication Administration Record (MAR) dated 4/1/24 through 6/27/24, lacked administration of the PRN albuterol inhaler.

Resident R50's physician orders dated 6/24/24, lacked orders for oxygen use.

Resident R50's progress notes identified:

- 6/4/24 at 1:03 p.m., the nursing assistant notified nursing of Resident R50's generalized weakness. Oxygen saturations were 87% and the nurse practitioner (NP) was notified.

- 6/4/24 at 6:43 p.m., the NP returned the phone call and orders for chest x-ray, covid test, blood work and oxygen at two LPM to keep oxygen saturations greater than 88%. Oxygen saturations were 86 % on room air and after oxygen was placed rose to 94%.

- 6/5/24 at 2:47 p.m., chest x-ray showed no acute abnormalities, covid test negative and no respiratory distress was observed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 23 245340 Department of Health & Human Services Printed: 09/22/2025 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 245340 B. Wing 06/27/2024

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

The Villas at St Paul 445 Galtier Avenue Saint Paul, MN 55103

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 0695 During an observation on 6/24/24 at 12:35 p.m., Resident R50 was in bed, an oxygen machine was running and set at two liters per minute (LPM). The nasal cannula or bubbler was not dated. Resident R50's nasal cannula (oxygen Level of Harm - Minimal harm or delivery tubing) was not in her nares but was on her bed mattress. Resident R50 had labored breathing as evidence potential for actual harm by nose flaring and grunting while taking deep breaths. Resident R50 was woken up and asked if she was breathing ok. Resident R50 said she was ok because she had her oxygen, she picked up the cannula and asked for help placing Residents Affected - Few it on and fell back asleep.

During a follow up observation and document review on 6/24/24 at 12:44 p.m., Resident R50's nasal cannula was properly placed in her nares, and breathing was regular.

Resident R50's medical record from 6/24/24, lacked a respiratory assessment, oxygen saturations, respiratory rate, or response to treatment identifying why oxygen was in use without an order in the electronic medical record. Resident R50's oxygen saturations (blood oxygen level), heart rate or respiratory rate had not been checked since 6/21/24, and at that time she measured 92% on oxygen (normal range is between 92% and 100%.)

During an interview on 6/24/24 at 6:48 p.m., nursing assistant (NA)-B stated she worked on Resident R50's hallway routinely, the oxygen had been in her room for a couple of weeks and the nurses were responsible for maintaining the oxygen. NA-B stated Resident R50 had shortness of breath occasionally and they would update the nurse if it occurred.

During an observation and interview on 6/25/24 at 1:58 p.m., Resident R50 was in bed with an oxygen concentrator in her room and it was not running. The nasal cannula was on the floor. Resident R50 asked where her oxygen tubing was and asked for it on. Resident R50's call light was activated, and NA-D entered the room. NA-D stated she worked with Resident R50 routinely and she had oxygen in use intermittently over the past couple of weeks. Registered nurse (RN)-B entered the room, picked the nasal cannula off the floor, and left to get new tubing. RN-B returned, put the tubing on the concentrator, turned it on to two LPM, placed the nasal cannula in Resident R50's nose and left

the room. RN-B had not completed a respiratory assessment before or after treatment with oxygen.

During an interview on 6/25/24 at 2:35 p.m. licensed practical nurse (LPN)-B stated he worked with Resident R50 today and if a resident required oxygen an order needed to be in place and monitoring should be completed. LPN-B stated he had not seen an order on the MAR for Resident R50 to use oxygen. LPN-B stated he saw oxygen in Resident R50's room over the past couple of weeks but had not checked if an order was in place.

During an interview on 6/25/24 at 3:28 p.m., RN-A stated she was familiar with Resident R50, and she had not required oxygen use historically, however, oxygen was in use at this time. RN-B stated a respiratory assessment should be documented with oxygen use and especially for residents with COPD due to the risk of retaining carbon dioxide in the lungs.

During a follow up interview on 6/25/24 at 3:32 p.m., RN-B reviewed Resident R50's orders and could not find an order for the oxygen he placed earlier today. RN-B agreed a respiratory assessment should be done before and

after oxygen therapy to assess effectiveness. RN-B was not sure if there was a risk in residents with COPD that were given oxygen without an assessment and was not sure if using Resident R50's PRN inhaler was an appropriate intervention to complaints of shortness of breath and would need to check on some things and follow up later.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 23 245340 Department of Health & Human Services Printed: 09/22/2025 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 245340 B. Wing 06/27/2024

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

The Villas at St Paul 445 Galtier Avenue Saint Paul, MN 55103

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 0695 During a second follow up interview on 6/25/24 at 3:57 p.m., RN-B found a written provider verbal/telephone order dated 6/4/24, for oxygen which had not gotten transcribed into the electronic medical record. The Level of Harm - Minimal harm or written order identified oxygen at two LPM via nasal cannula to keep oxygen saturations greater than 88%. potential for actual harm RN-B agreed he had not checked oxygen saturations before implementing in accordance with the provider orders. Residents Affected - Few

During an observation on 6/26/24 at 10:21 a.m., Resident R50 was in bed with the oxygen concentrator running and

the nasal cannula on the floor. Resident R50 asked for her inhaler. LPN-C was notified and entered the room, Resident R50 stated her inhaler was on the floor, LPN-C looked on the floor and stated there was no inhaler. LPN-C asked if Resident R50 meant her oxygen cannula, handed it to her, but stated he needed to get new tubing since it was on

the floor. LPN-C was asked by surveyor if giving the albuterol inhaler PRN would be appropriate for Resident R50's complaints of shortness of breath and he stated he would have to talk to the nurse manager. LPN-C left Resident R50's room and had not checked oxygen saturations nor completed a respiratory assessment.

During an interview on 6/26/24 at 2:49 p.m., the director of nursing (DON) stated oxygen use and respiratory assessments should be based on provider order and nursing judgement.

A policy for respiratory assessments was requested and not provided. Instead, the facility's undated standing house orders (SHO) were provided, which identified one week and one month after admission; a resident's temperature, pulse, respirations, blood pressure and oxygen saturations would be checked monthly unless directed otherwise. The SHO lacked detail for respiratory assessments with oxygen use or shortness of breath.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 23 245340 Department of Health & Human Services Printed: 09/22/2025 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 245340 B. Wing 06/27/2024

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

The Villas at St Paul 445 Galtier Avenue Saint Paul, MN 55103

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 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42579 potential for actual harm Based on observation, interview, and document review, the facility failed to ensure staff utilized enhanced Residents Affected - Few barrier precautions (EBP) for 1 of 2 residents (Resident R48) observed during tube feeding cares.

Findings include:

Resident R48's quarterly minimum data set (MDS) dated [DATE REDACTED], identified she was rarely/never understood, was totally dependent on staff for bed mobility and transfers, and extensive assist was required for eating. Diagnoses included stroke, aphasia (loss of speech) and diabetes. Resident R48 had malnutrition and received tube feeding for nutrition.

Resident R48's tube feeding care area assessment (CAA) dated 3/22/24, triggered related to receiving tube feeding for all nutritional needs. Staff were directed to continue to administer tube feeding as ordered, monitor for complications and proceed to care plan.

Resident R48's care plan dated 3/29/24, identified EBP was placed related to tube feeding and chronic pressure wounds, and staff were directed to don/doff personal protective equipment (PPE) per EBP when high contact cares were provided.

Resident R48's active orders dated 6/14/24, identified to follow EBP while tube feedings were provided, when the feeding tube and associated equipment were handled, when insertion site care was provided, and other high contact care activities.

During an observation on 6/24/24 at 1:35 p.m., Resident R48's door had an EBP sign on door directing staff to wear gloves and a gown for high contact care including device care and feeding tube. There was PPE bin hanging

on the door containing gloves, goggles, and gowns.

During an observation on 6/25/24 at 12:44 p.m., licensed practical nurse (LPN)-A entered Resident R48's room, put on gloves but not a gown, pulled back Resident R48's bedsheet, undid the abdominal binder holding Resident R48's tube feeding line in place, entered the bathroom obtained water in a graduated cylinder, filled up a syringe from the cylinder and flushed the feeding tube with water. LPN-A refastened the abdominal binder, covered Resident R48 back up with the sheet, changed gloves, filled the tube feeding water flush bag in the bathroom sink faucet, re-entered Resident R48's room, spiked the tube feeding formula bottle, and programmed the tube feeding pump which then primed the tubing. LPN-A connected the tubing to Resident R48's feeding tube and exited the room.

During a follow up interview on 6/25/24 at 12:56 p.m., LPN-A stated she was told by someone she could not remember who, that she was not required to follow EBP during tube feeding cares, despite the signage on

the door and order in the electronic medical record.

During an interview on 6/25/24 at 1:19 p.m., the director of nursing (DON) stated staff should wear PPE in accordance with EBP for device cares such as tube feedings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 23 245340 Department of Health & Human Services Printed: 09/22/2025 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 245340 B. Wing 06/27/2024

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

The Villas at St Paul 445 Galtier Avenue Saint Paul, MN 55103

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 The facility policy titled EBP dated 4/1/24, identified the use of gowns and gloves were required for high contact cares for residents at increased risk of multidrug resistant organism (MDRO) acquisition. Therefore, Level of Harm - Minimal harm or EBP would be implemented for all residents with indwelling medical devices such as catheters and feeding potential for actual harm tubes, even if the resident is not known to be infected or colonized with an MDRO.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 23 245340

F-F0800, Staff Assessment of Daily and Activity Preferences. A dash, indicating the question was not assessed, was identified on all of the questions for

F-F561.

The Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.18.11, dated October 2023, indicated the purpose of the manual was to offer clear guidance about how to use the resident assessment instrument (RAI) correctly and effectively to provide appropriate care. The RAI helps nursing home staff gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan. Under the heading, Section F: Preferences for Customary Routine and Activities, indicated the intent was to obtain information regarding

the resident's preferences for their daily routine and activities. Further, this is best accomplished when the information is obtained directly from the resident or through family or significant other, or staff interviews if

the resident cannot report preferences.

Resident R74's admission Minimum Data Set (MDS) dated [DATE REDACTED], indicated Resident R74 was in room [ROOM NUMBER]-1 and had intact cognition, did not have delirium, disorganized thinking, altered level of consciousness, hallucinations, delusions, physical, verbal, or other behavioral symptoms, and did not reject care. Additionally, the MDS indicated Resident R74 was dependent on staff for showering and bathing. Further, the MDS indicated an interview for preferences including for receiving a tub, shower, or bed bath should be conducted, however was not assessed. Under section F, number