Southview Acres Healthcare Center

F-F142 had diagnoses of encounter for orthopedic aftercare following surgical amputation, type II diabetes (a condition in which the pancreas doesn't make enough insulin causing the body to have trouble controlling blood sugar and using it for energy), local infection of the skin and subcutaneous tissue, atherosclerotic heart disease (damage or disease in the heart's major blood vessels), essential hypertension (abnormally high blood pressure that's not the result of a medical condition) , chronic kidney disease, induced constipation, occlusion and stenosis of right carotid artery (narrowing of the right carotid artery), right buttock pressure ulcer, anxiety disorder, irritable bowel syndrome (a digestive condition that causes pain, gas, diarrhea, and constipation), benign prostatic hyperplasia (enlargement of the prostate gland that causes problems with urination), retention of urine, hemorrhoids, and lower back pain.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 10 245189 Department of Health & Human Services Printed: 09/11/2025 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 245189 B. Wing 01/09/2025

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

Southview Acres Healthcare Center 2000 Oakdale Avenue West Saint Paul, MN 55118

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 Resident R142's Clinical Orders report, printed on 1/8/25 indicated orders for weekly bath audits, Pro-source liquid 30 milliliters (ml) every day, nurse to monitor APM mattress pump (pressure relieving speciality mattress) is well Level of Harm - Minimal harm or functioning every shift. Resident R142's report did not include skin care orders. potential for actual harm Resident R142's Braden scale (a tool used to assess a patient's risk of developing pressure ulcers, or pressure Residents Affected - Few injuries) dated 11/12/24, indicated a score of 15, which indicated Resident R142 was at risk to develop a pressure area.

Resident R142's care plan initiated on 8/6/24, indicated Resident R142 had impairment to skin integrity. Resident R142's care plan goal indicated the resident will develop clean and intact skin by the review date. The goal also indicated Pressure ulcer stage 2 right intergluteal cleft, healed 12/7/24.

Care plan interventions indicated:

- Intervention dated: 8/26/24: Apply barrier cream after each incontinent episode with a revision date of 8/6/24.

- Intervention dated: 8/26/24: Keep skin clean and dry. Use lotion on dry skin with a revision date of 8/6/24.

- Intervention dated: 8/26/24: The resident needs pressure reducing cushion to protect the skin while in wheelchair. Revision date 8/6/24.

- Intervention dated: 8/26/24: The resident needs a pressure relieving mattress, APM, pillows to protect the skin while in bed. Revision date 11/21/24.

- Intervention dated: 12/9/24: Encourage good nutrition and hydration to promote healthier skin. No revision dates.

- Intervention dated: 12/9/24: Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, s/sx [sign and symptoms] of infection, maceration, etc., to MD. No revision dates.

- Intervention dated: 12/9/24: Treatment per order. Revision date 1/8/24.

Resident R142's care plan listed no further updates following 12/9/24.

On 12/24/24 Resident R142's transferred to the hospital emergency department for evaluation due to blood in the stool. The emergency department's Summary report dated 12/24/24, indicated lower gastric bleed was ruled out and included the following laboratory reports:

Hepatic Function Panel: Albumin 3.8 low (normal 4.0-4.9)

Complete blood count (CBC): red blood count 4.11 low (normal 4.30-5.90), hemoglobin 11 low (normal 13. 5-17.5).

Resident R142's progress note authored by Resident R142's primary physician dated 1/9/25, indicated the following laboratory tests results dated 7/29/24: red blood count 3.7 low, and hemoglobin 9.8 low.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 10 245189 Department of Health & Human Services Printed: 09/11/2025 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 245189 B. Wing 01/09/2025

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

Southview Acres Healthcare Center 2000 Oakdale Avenue West Saint Paul, MN 55118

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 Resident R142's weekly bath audits completed between 12/7/24 and 1/1/25 indicated no skin impairments.

Level of Harm - Minimal harm or Resident R142's progress note dated 1/4/25 at 3:04 p.m. indicated Resident R142 had a shower, his skin was checked and potential for actual harm appears intact with no signs of concerns or abnormalities.

Residents Affected - Few Resident R142's progress note dated 1/5/24 at 8:25 p.m. stated patient is breaking down on the coccyx area due to refusing to be repositioned while sitting in his chair.

During observation and interview on 1/7/25 at 2:38 p.m., Resident R142 stated he had a bowel movement and requested to be changed. Nursing assistant (NA)-D applied Resident R142's prosthetic leg and assisted him to stand up. NA-D cleaned Resident R142 perineal (rectal area) area and Resident R142 moaned in pain and said, it hurts! RN-C came into the room and verified the two pressure areas but said she didn't feel comfortable staging affected area, RN-C observed a pressure area, on each buttock; she measure the pressure area on the left buttock measured about two centimeters (cm) in length and one cm in width, and the pressure area on his right buttock measured one by one cm.

During observation and interview on 1/7/25 at 3:06 p.m., registered nurse (RN)-E verified Resident R142 skin breakdown. RN-E stated his bottom had healed but stated every time Resident R142 takes antibiotics, he gets diarrhea, and his bottom opens. RN-E proceeded to cleanse the area and applied alginate powder and Vitamin A and D cream.

Duirng interview on 1/7/25 at 3:17 p.m., NA-E stated all nursing assistants received training about how to care for him. We use a barrier cream for this bottom. Everytime we go to his room he is on the phone. He is busy and asks us to come back. We use the Kardex.

During interview on 1/7/25 at 3:20 p.m., nurse manager RN-C stated she was not aware of any documentation on Resident R142's progress notes about the skin breakdown on his coccyx (bottom) area. RN-C stated she would look at Resident R142's skin later in the afternoon.

During interview on 1/7/25 at 3:42 p.m., NA-D stated since yesterday, Resident R142 complained of buttocks' pain

during toileting cares. NA-D stated they always apply barrier cream after they clean him up. NA-D stated Resident R142 often refuses to reposition and likes to sit down on his recliner chair for most of the day. NA-D stated his Kardex indicated repositioning every two hours and walking once a day. NA-D stated Resident R142 used his call light to request help. NA-D stated the nursing assistants would inform the nurses of Resident R142 refusal of cares.

During interview on 1/7/25 at 3:55 p.m., licensed practical nurse (LPN)-D stated he worked on January 5th and when he cleaned Resident R142's coccyx and buttocks, Resident R142 complained of pain. LPN-D stated he observed Resident R142 had a new pressure area on his right buttock and the skin in both buttocks was red. LPN-D documented in the progress notes, Resident R142's skin had started to breakdown. LPN-D stated when he moved from the 1st floor TCU unit to the current unit, he had a pressure area on his right buttock which healed a few weeks ago. LPN-D stated on 1/5/24, he performed the same treatment used for his previous pressure area. LPN-D left a voice mail for the nurse manager, RN-C because he knew the next day [Monday] the facility's wound team would make rounds.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 10 245189 Department of Health & Human Services Printed: 09/11/2025 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 245189 B. Wing 01/09/2025

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

Southview Acres Healthcare Center 2000 Oakdale Avenue West Saint Paul, MN 55118

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 interview on 1/8/25 at 8:47 a.m., RN-C stated Resident R142 had a pressure area on his right buttock that healed. RN-C stated when a resident developed a new pressure area, the nurse needed to complete a Level of Harm - Minimal harm or Braden Scale, a wound evaluation, and determine what happened and how to prevent future occurrences. potential for actual harm RN-C verified Resident R142's skin care plan did not include any turning and reposition schedule, RN-C said I missed it. RN-C veirifed there was no consistent documentation of resident's refusal to turn and reposition, and Residents Affected - Few added that should have been considered when Resident R142 was re-assessed after his previous pressure ulcer healed. RN-C stated on 1/7/24 she visualized Resident R142's skin and obtained an order to apply collagen powder over affected area and Vitamin A and D cream over affected area. RN-C stated he had not measured the affected areas and was going to request the assistance of their lead wound nurse to classify Resident R142's coccyx skin breakdown.

During observation and interview on 1/8/25 at 12:17 p.m., Resident R142 was sitting on recliner and NA-D assisted him to lay down in bed. The director of nursing (DON), RN-C and lead wound nurse/RN-D were present in

the room to observe affected areas. RN-C and DON verified Resident R142 had a stage II pressure area on each buttock. RN-C used a digital program to measure the pressure areas. The pressure area on his left buttock measured 2.3 cm in length by 1.9 cm in width, and the pressure area on his right buttock measured one by one cm.

During interview on 1/8/25 at 12:43 p.m., the director of nursing (DON) stated when a pressure area heals,

the facility continues to monitor the wound for two more weeks. The monitoring is done by the Integrated Wound practitioner. The facility then implements measures to prevent re-occurrence which includes the use of a barrier cream, repositioning resident, the use of a specialty mattress, and a cushion for his chair. DON added, changes to the existing care plan are made if indicated. The DON stated when a new skin impairment area was identified, she expected the nurses to do a skin assessment, educate the resident to lay down and reposition, call the physician to obtain orders to start a treatment, complete a Braden scale and an Incident Report on the resident's electronic record which would alert the nurse manager and her (DON) about any new skin impairment.

During interview on 1/0/25 at 10:34 a.m., physician assistant (PA)-A stated when a resident develops a pressure area he needs to be notified as soon as possible, so a resident can be re-assessed by the wound care team. PA-A stated when a pressure area is not addressed right away the ulcers can increase in size, cause pain, also pressure areas are an avenue for infections. PA-A stated he was not notified about the new pressure areas.

During interview on 1/9/25 at 11:58 a.m., registered dietician (RD)-A stated on Monday morning during their interdisciplinary team meeting (IDT), the nurse manager, RN-C reported Resident R142 had a new area of skin impairment associated with moisture. RD-A stated on 1/8/25 she re-assessed Resident R142 and kept him on Pro-source nutritional supplement. RD-A stated she had not been informed about Resident R142's new pressure wounds areas and even with this Resident R142's Pro-Sources orders would not need adjustment. RD-A stated Resident R142's intake was adequate and his weight was stable, and she felt Resident R142 had what he needed to heal his pressure area. RD-A stated she had not reviewed Resident R142's most recent albumin level because the level could be affected by inflammation and other medical conditions. RD-A stated she trusted the hemoglobin and oxygenation levels more. Resident R142's Nutrition Assessments dated 8/7/24, 11/12/24, and 12/2024 lacked documentation of hemoglobin and/or albumin levels.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 10 245189 Department of Health & Human Services Printed: 09/11/2025 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 245189 B. Wing 01/09/2025

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

Southview Acres Healthcare Center 2000 Oakdale Avenue West Saint Paul, MN 55118

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 interview on 1/9/25 at 12:19 p.m., lead wound nurse, RN-D stated Resident R142 risked further skin breakdown if action is delayed after a new skin impairment area is identified. RN-D stated if a pressure area Level of Harm - Minimal harm or goes unchecked, it will get worse. RN-D stated the development of a new pressure area represents a potential for actual harm change in condition and the physician needed to be notified right away.

Residents Affected - Few 44656

Resident R39

Resident R39's quarterly Minimum Data Set (MDS) dated [DATE REDACTED], identified Resident R39 with severe cognitive impairment, did exhibit rejection of cares, had an indwelling catheter (tube and bag to drain urine from the bladder), diagnoses of kidney disease, neurogenic bladder (nerve damage to bladder), obstructive uropathy (blockage of urine flow) , dementia, Parkinson's disease, malnutrition, and chronic obstructive pulmonary disease (damaged lungs that limit airflow in and out of lungs). In addition, Resident R39 was indentified as at risk for pressure ulcers, had one stage 2 pressure ulcer acquired at the facility, had two stage 3 pressure ulcers that were present upon admission/entry or reentry to facility, utilized pressure reducing device for chair and bed, and received pressure ulcer/injury care.

Resident R39's physician orders (PO) with a start date of 11/15/2024, documented the following order for Resident R39 Pillow between knees when in bed for comfort and another order with a start date of 5/20/24, Resident R39 is to have blue wedge abductor [device to prevent tissue breakdown] with strap in place when in w/c [wheelchair] on days/evening to help separate knees and to between position feet.

Resident R39's nursing assistant care sheet (Kardex) dated 1/8/25, identified Resident R39 required the following:

The resident needs assistance to turn/reposition at least every 2 hours, more often as needed or requested;

Encourage Resident to frequently shift weight;

Extensive assist/one-person physical assist One Person assist with turning and repositioning when in bedTwo [sic] persona assist to boost up in bed;

Application of pillow between knees when in bed;

Lower blue knee abductor wedge with strap to be used when up in w/c to help separate knees and to better position feet.

During observation on 1/6/25 at 5:38 p.m., Resident R39 was observed seated in a Broda chair (specialized positioning wheelchair) in dining room watching television without the ordered protection between his knees.

During observation on 1/7/25 at 8:05 a.m., Resident R39 was observed in bed without padding between the knees.

During observation on 1/7/25 at 3:41 p.m., Resident R39 was observed seated in a Broda chair in the dining room watching television without the ordered blue wedge abductor in place.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 10 245189 Department of Health & Human Services Printed: 09/11/2025 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 245189 B. Wing 01/09/2025

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

Southview Acres Healthcare Center 2000 Oakdale Avenue West Saint Paul, MN 55118

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 observation on 1/8/25 at 8:43 a.m., Resident R39 was observed lying in bed, positioned on his right side with no pillow or padding between knees. Level of Harm - Minimal harm or potential for actual harm During interview with NA-A on 1/8/25 at 12:58 p.m., NA-A stated, I get report from the previous shift verbally and look at kardex to tell me what they [residents] need. NA-A stated every resident has a kardex and [it tells Residents Affected - Few us] what we need to do. We also look in the computer care plan to tell what needs to be done.

During observation and interview with nurse manager registered nurse (RN-A) on 1/9/25 at 10:46 a.m., RN-A identified Resident R39 was lying in bed with no pillow between his knees. RN-A stated, [Resident R39's] care plan says to have pillow between knees when in bed. His legs are contracted enough to be touching and we want to eliminate or reduce pressure injuries to the area.

During observation and interview with LPN-A on 1/9/25 at 10:54 a.m., LPN-A verified there was no pillow or padding between Resident R39's knees while he was lying in bed. LPN-A stated, yeah, [Resident R39] is on a turning schedule. [Resident R39] can't move himself unless we help him. He is a high skin breakdown risk. And Padding or something should be between [Resident R39] knees. It says so in the care plan and should be done. His knees bed inwards to touch so there needs to be something between them when he is in bed and in the wheelchair.

During observation and interview with NA-A on 1/9/25 at 10:55 a.m., NA-A stated, [Resident R39] is a skin breakdown risk, a pillow should be between the knees when in bed and it is not.

During interview with assistant director of nursing (IPCP) on 1/8/25 at 2:29 p.m., IPCP stated the expectation of facility direct care staff is to follow the kardex and care plan for positioning and applying the blue wedge pillow between Resident R39's knees when up in wheelchair and pillow between knees when in bed. IPCP stated Resident R39 was identified as high risk for pressure ulcers with interventions in place.

Facility's policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol dated 7/12/22 indicated the nursing staff and practitioner will assess and document an individual's significant risk factor for developing pressure ulcers, for example, immobility, recent weight loss, and a history of pressure ulcers. In addition, the nurse shall describe and document/report the following:

a. Full assessment of pressure sore including location, stage, length, with and depth, presence of exudates or necrotic tissue.

b. Pain assessment.

c. Patient's mobility status.

d. Current treatments, including support surfaces; and

e. All active diagnoses.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 10 245189

F-F638].

On 1/6/25 at 2:04 p.m., Resident R108's room was observed from the public hallway with her room door being left wide open. Resident R108 was lying in bed with a mobile cart placed adjacent to the room doorway in the hallway at a ninety-degree angle, and two staff members were inside the room dressed in disposable gowns and tending to Resident R108's leg. The two staff members were completing a dressing change to Resident R108's leg and each time the one staff member moved to the side, red-colored tissue and associated bodily drainage was exposed on Resident R108's leg. After a few minutes of observation, Resident R108 noticed the surveyor standing in the hallway watching

the wound care and asked aloud, What's he doing out there? The two staff members turned and looked at

the surveyor in the hallway when one staff responded, Maybe looking for someone, I don't know. However, no attempt to close the doorway was offered or made at this time and Resident R108 continued to make several looks at the surveyor who remained in the public hallway.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 10 245189 Department of Health & Human Services Printed: 09/11/2025 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 245189 B. Wing 01/09/2025

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

Southview Acres Healthcare Center 2000 Oakdale Avenue West Saint Paul, MN 55118

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 0583 At 2:08 p.m., the director of nursing (DON) approached the surveyor and Resident R108's room from down the hall. DON observed Resident R108's open doorway along with the care inside, and was questioned if they knew why the Level of Harm - Minimal harm or door would be left open for such. DON responded, No, I don't, and identified the one staff member in the potential for actual harm room as registered nurse manager (RN)-D. DON stated Resident R108 could be super particular and she would follow-up. DON then approached Resident R108's room and asked if the door could be closed when RN-D aloud Residents Affected - Some responded, She wants it open. Resident R108 then voiced aloud, I have nothing showing. DON returned to the surveyor and expressed she would review the care plan to ensure the door being open was outlined.

Resident R108's care plan, revised 11/27/24, identified a section labeled, Personalized Care ., which outlined an intervention reading, Going outside for fresh air: Very important 12/4/24: Fresh air is very important. Keep door open at all times, unless changing brief. In addition, a subsequent section outlined, ADL self care needs, included an intervention reading, PERSONAL HYGIENE/ORAL CARE . -Patient feels Claustrophobic. Door to room to remain open at all times, unless commode, or Brief change. This intervention was listed as being revised, 01/06/2025. The care plan lacked information on what, if any, other options had been attempted or offered to Resident R108 to ensure personal privacy was maintained for her and others.

On 1/6/25 at 2:53 p.m., Resident R108 was interviewed in her room. Resident R108's room had two ceiling-mounted tracks installed for privacy curtain(s), however, no physical curtains were installed on these tracks. Resident R108 verified

she wanted the doorway left open due to being very claustrophobic, and voiced if anyone saw inside while care was happening, such as the observed wound care, then such was their problem and not mine. Resident R108 stated they resided in a medical care center and people should expect to see things which may be unsightly adding, That's reality. However, Resident R108 stated nobody from the care center had asked or offered other options to her prior (i.e., turning mobile cart to cover door entrance, portable curtains) but, again, reiterated aloud it wasn't her concern adding, No, because I don't think it's an issue.

Resident R108's medical record was reviewed and lacked evidence what, if any, additional options had been offered or attempted to provide as much privacy as able for Resident R108 and others (i.e., passerby's) during the provision of care with exposed wound tissue and potential bodily fluid (i.e., blood).

On 1/7/25 at 12:23 p.m., social services designee (SSD)-B and RN-D were interviewed. RN-D verified they were providing care which was visible from the hallway and felt nothing was flowing [i.e., blood] but acknowledged the wound tissue would be visible adding, [The] red tissue would have been very visible. SSD-B stated Resident R108's room was somewhat isolated down towards the end of the hallway, however, acknowledged they had not addressed what, if any, options were available to ensure Resident R108's privacy and others' was maintained adding, We have not thought of that. SSD-B stated if Resident R108's room had been located

in a more heavy traffic area, then it would have been addressed they felt. RN-D verified the care center had, at least at one time, some portable privacy screens which would allow the door to be kept open. RN-D explained the interdisciplinary team (IDT) had discussed using one of them prior, however, then questioned how it would be stored or cleaned. RN-D stated turning the mobile cart (used for wound supplies) to cover

the door would be good adding aloud, I think that would be a very easy option. RN-D verified Resident R108 did, at times, allow her doorway to be closed partially, too, with cares prior. RN-D and SSD-B both verified evidence of what, if any, options had been offered or presented to Resident R108 for privacy with wound care should have been documented in the medical record. Further, RN-D stated it was important to ensure privacy was maintained adding aloud, It's a dignity issue for all involved.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 10 245189 Department of Health & Human Services Printed: 09/11/2025 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 245189 B. Wing 01/09/2025

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

Southview Acres Healthcare Center 2000 Oakdale Avenue West Saint Paul, MN 55118

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 0583 A provided Confidentiality of Information and Personal Privacy policy, dated 12/2021, identified the care center would safeguard personal privacy. The policy outlined, The facility will strive to protect the resident's Level of Harm - Minimal harm or privacy regarding . b. medical treatment . d. personal care. potential for actual harm 44656 Residents Affected - Some EXPOSED RESIDENT INFORMATION:

During observation on 1/8/25 at 1:44 p.m., a medication cart for second floor residents was left unattended with a patient care sheet which contained personal information including name, room number, personal preferences, physical and food assistance needs. The facility was under construction with six contracted flooring employees installing laminate flooring in the second floor hallway where the unattended medication cart was located.

During interview on 1/8/25 at 1:46 p.m., with facility administrator who walked by the unattended cart, the administrator stated, this [pointing to patient care sheet] should not be visible. This is private information. The administrator placed the care sheet face down under some papers on the medication cart.

During interview with facility assistant director of nursing (IPCP) on 1/8/25 at 2:29 p.m., the IPCP stated resident personal information contained in the Care sheet should not be left unattended for Privacy matter.

During interview with registered nurse (RN-A) on 1/9/25 at 10:46 a.m., RN-A stated, care sheets with patient information should not be left unattended. Someone could look at the patient information which they have no business doing.

During interview with nurse manager of second floor (RN-C) on 1/9/25 at 1:37 p.m., RN-C stated, Care sheets should never be left unattended on the cart. For HIPPA (health information portability privacy act). RN-C stated the medication cart in question would be assigned the nurse passing medications for two wings of the facility where the laminate flooring was being installed and the care sheet included 25 residents and their information.

Facility policy titled Confidentiality of Information and Personal Privacy dated reviewed 12/08/2021, The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. In addition, The facility will strive to protect the resident's privacy regarding his or her:

a. accommodations;

b. medical treatment;

c. written and telephone communications;

d. personal care;

e. visits; and

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 10 245189 Department of Health & Human Services Printed: 09/11/2025 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 245189 B. Wing 01/09/2025

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

Southview Acres Healthcare Center 2000 Oakdale Avenue West Saint Paul, MN 55118

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 0583 f. family and resident group meetings.

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 10 245189 Department of Health & Human Services Printed: 09/11/2025 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 245189 B. Wing 01/09/2025

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

Southview Acres Healthcare Center 2000 Oakdale Avenue West Saint Paul, MN 55118

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** 48065 potential for actual harm Based on observation, interview, and document review the facility failed to comprehensively assess, care Residents Affected - Few plan, and implement interventions to prevent recurrent pressure ulcers for 2 of 2 resident (Resident R39 and Resident R142) who had a history of pressure ulcers.

Findings include:

Resident R142

The Centers for Medicare (CMS) State Operations Manual (SOM) Appendix PP, dated 8/8/2024, identified definitions for pressure ulcer care and treatment. This included, Avoidable, being outlined as, . the resident developed a pressure ulcer/injury, and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors, define and implement interventions that are consistent with resident needs . monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. In addition, the guidance provided several stages of injury definition which included, Stage II Pressure Ulcer: Partial-thickness skin loss with exposed dermis . presenting as a shallow open ulcer. Adipose (fat) is not visible and deeper tissues are not visible. This stage should not be used to describe moisture associated skin damage including incontinence associated dermatitis .

During interview on 1/7/25 at 1:51 p.m., Resident R142 was observed seated on his recliner, watching television. Resident R142 stated he had a bed sore on his bottom. Resident R142 stated the bed sore was going to get worse because the area was not covered with a dressing, and the staff only applied a cream. Resident R142 stated the staff is supposed to get me up or turn me every two hours, but they don't. Resident R142 stated he was also concerned about having to wait too long for staff to help him when he is incontinent of bowel. Resident R142 stated yesterday, 1/6/25, he returned from a doctor's appointment and informed the nurse on duty he had a bowel movement and needed to be changed. Resident R142 stated he waited one hour and 15 minutes before he was cleaned.

Resident R142's quarterly Minimum Data Set (MDS) dated [DATE REDACTED], indicated Resident R142 was cognitively intact, had no behaviors, did not refuse cares, needed set-up for oral hygiene and eating, and required maximal assistance with mobility and all activities of daily living (ADL). The MDS also indicated Resident R142 had no pressure ulcers.

Resident R142's Clinical Diagnosis report printed on 1/8/24, indicated