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 17 of 34 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 18 of 34 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 19 of 34 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 20 of 34 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 21 of 34 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 22 of 34 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 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48065

Residents Affected - Few Based on observation, interview and document review, the facility failed to ensure bladder and bowel incontinence was comprehensively assessed and interventions developed to promote continence for 2 of 2 resident (Resident R142, Resident R139) reviewed for incontinence cares.

Findings include:

Resident R142

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 outlined Resident R142 was always incontinent of bowel.

A trial of toileting program (e.g., scheduled toileting) had not been attempted since admission to this facility. Furthermore, the toileting program and bowel pattern section of the MDS was left blank.

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

Resident R142's physician orders printed 1/9/24, included orders for polyethylene Glycol 3350 (medication for constipation) oral packet 17 grams once a day and sennosides-docusate sodium (medication for constipation) oral tablets 8.6-50 milligrams, one tablet once a day. Both medications are used for constipation.

Resident R142's care plan dated 10/7/24, indicated Resident R142 has bowel incontinence with a goal for Resident R142 to be continent

during daytime through the review date. Care plan's intervention dated 10/7/24, indicated taking resident to

the toilet upon request with a revision date of 10/7/24. Other interventions dated 12/17/24, indicated checking resident every two hours and assisting with toileting, and to provided pericare after each incontinence episode.

Resident R142's Bowel and Bladder Program Screener dated 12/26/24 indicated resident was a candidate for a bowel training program.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 34 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 0690 During interview on 1/7/24 at 1:51 p.m., Resident R142 stated he requests to use the toilet to sit down and try to have

a bowel movement in the toilet and added especially when I have a pressure sore. Resident R142 stated, sometimes I Level of Harm - Minimal harm or can't wait 15 or 20 minutes and I just go in my pants and it upsets me. Resident R142 stated sometimes after having potential for actual harm an incontinent episode of bowel, he waits over one hour to be changed and it will be easier if they help him sit down in the toilet. Residents Affected - Few

During interview on 1/7/25 at 2:38 p.m., nursing assistant (NA)-D stated Resident R142 used his call light when he needs assistance to be changed or to be transferred to the toilet. NA-D stated usually Resident R142 was incontinent of bowel.

During interview on 1/8/25 at 8:57 a.m., registered nurse (RN)-C stated Resident R142 doesn't feel when he has a bowel movement, and he is assisted to the toilet upon request. RN-C added, I think when he gets stronger it will be easier for him to transfer to the toilet. RN-C stated she had not monitored Resident R142 to establish a possible pattern and had not considered a bowel schedule or program for the resident.

During interview on 1/8/24 at 1:09 p.m., director of nurses (DON) stated if a patient has bowel incontinence and they are not happy about it, I will expect the team to talk to the patient and find out his goals. This will improve the patient's quality of life and meet the goals he/she has set for themselves.

49339

Resident R139

Resident R139's quarterly Minimum Data Set (MDS), dated [DATE REDACTED], identified Resident R139 was cognitively intact and required substantial/maximal staff assistance with toileting care. Further, the MDS outlined Resident R139 as being always incontinent of urine, however, a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) had not been attempted on admission/reentry or since urinary incontinence was noted in this facility. Furthermore, the current toileting program or trial section was left blank.

During interview on 1/06/25 at 1:12 p.m., Resident R139 stated she can sense when she has to urinate and stated she would like to be able to use the toilet instead of going in her incontinence pad. Resident R139 stated staff do not offer to bring her to the bathroom to use the toilet and this would be her preference.

During a follow up interview on 1/09/25 at 9:41 a.m., Resident R139 was observed lying in bed. Resident R139 once again, expressed a desire to be able to use the toilet. Resident R139 stated, I don't like to go in my underwear. Resident R139 stated most of the time she can feel when she has to urinate. Resident R139 stated staff do not offer to bring her to the bathroom or to use a bedpan [a device used as a receptacle for the urine and/or feces of a person who is confined to a bed] and added they just change my pad. Resident R139 stated she feels confident that she can sit on

the toilet with support as she has been working with physical therapy for a long time. Resident R139 stated, they offered me a bedpan a long time ago, which wasn't the best, but they don't even offer that let alone the toilet.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 34 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 0690 Resident R139's care plan, printed 1/9/25, identified Resident R139 requires extensive assist x 1 staff for toilet use. Furthermore, the care plan identified Resident R139 is incontinent of bladder, impaired mobility and listed a goal which Level of Harm - Minimal harm or read, INCONTINENT: Check (with cares every AM, PM, Before or after meals and on first and third rounds at potential for actual harm night and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN [as needed]

after incontinence episodes. The care plan lacked evidence, or subsequent interventions of a current or past Residents Affected - Few toileting program (scheduled toileting, prompted voiding or bladder training), or preference to use the toilet.

Resident R139's progress notes, dated 9/9/24 to 1/9/25, were reviewed and lacked evidence of a toileting program attempted. Furthermore, the progress notes lacked evidence of offering Resident R139 the use of a toilet or a bedpan.

Resident R139's Order Summary Report, printed 1/9/25, lacked evidence of toileting program.

Resident R139's Kardex, printed 1/8/25, indicated TOILET USE: Resident requires extensive assist x 1 staff.

On 1/07/25 at 3:50 p.m., nursing assistant (NA)-B stated they are familiar with Resident R139. NA-B stated Resident R139 was incontinent of bowel and bladder. NA-B stated they know of Resident R139 using the bedpan once previously, about 2-3 months ago but not since. NA-B stated they do not offer to put Resident R139 on the toilet and just provide incontinent cares for Resident R139. NA-B indicated that Resident R139 was able to identify when she needs incontinence cares completed.

On 1/08/25 at 12:34 p.m., NA-A verified they are familiar with Resident R139 and indicated Resident R139 was on incontinence checks. NA-A indicated they have not offered Resident R139 to use the toilet or the bedpan. NA-A verified they refer to the Kardex for resident needs.

On 1/09/25 at 10:05 a.m., NA-C indicated Resident R139 does not use a bedpan or the toilet. NA-C indicated Resident R139 will ask to be changed when needed as Resident R139 was able to identify when they need to be changed. NA-C verified they have not offered Resident R139 the bedpan or the use of the toilet.

On 1/09/25 at 9:52 a.m., licensed practical nurse (LPN)-C indicated they were unsure if Resident R139 was offered

the bedpan or toilet. LPN-C indicated Resident R139 was on scheduled to have her incontinence pad check and changed.

On 1/08/25 at 1:11 p.m., registered nurse (RN)-C verified they are familiar with Resident R139. RN-C indicated Resident R139 was incontinent of bowel and bladder. RN-C indicated they attempted to transfer Resident R139 to use the toilet but unable to recall when. RN-C indicated they offered Resident R139 the use of the bedpan and indicated that was more than 6 months ago. RN-C indicated they would look for documentation regarding this.

During a follow-up interview on 1/08/2025 at 2:40 p.m., RN-C indicated they could not find any documentation around offering the use of the toilet or bedpan. RN-C indicated, most cognitively intact people want to use the toilet.

On 1/08/25 at 1:30 p.m., physical therapist (PT)-A verified Resident R139 was currently receiving physical therapy services and was discharged from occupational therapy services on 12/20/24. PT-A stated, Generally speaking, if someone is able to use an EZ-Stand [manual standing aid to allow patients to assist themselves

in preparation for transferring], they can use a toilet, maybe not be left alone.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 34 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 0690 On 1/09/25 at 10:56 a.m., PT-B verified Resident R139's last physical therapy was 1/6/24 and Resident R139 used the EZ stand. PT-B indicated, I don't know why that would be a problem if they can sit safely on the toilet, when Level of Harm - Minimal harm or asked about a resident using a toilet when transferring with a mechanical lift. potential for actual harm

On 1/09/25 at 1:34 p.m., physical therapy assistant (PTA)-A verified they are familiar with Resident R139. PTA-A Residents Affected - Few verified Resident R139 transfers with an EZ stand and indicated there have been no updates sent to nursing in 6-12 months, on recommendations changing how Resident R139 transfers.

On 1/09/25 at 1:55 p.m., director of nursing (DON) indicated a toileting program/schedule that is implemented is based on individual needs of resident that would include potential, preferences and the needs of the patient. DON indicated Resident R139 has some has an impaired awareness of what is happening with her body and indicated there was question regarding trunk support to support her on the toilet. DON stated

they were going to look for additional documentation.

On 1/09/25 at 2:45 p.m., DON provided a occupational therapy discharge summary for dates of service 7/5/24-9/17/24. The goal indicated pt will have appropriate toileting program in place with nursing follow thru to increase quality of life and manage incontinence was discontinued on 9/17/24 noting pt not tolerating. No success when on toilet previously and not motivated for goal. The document lacked evidence of interventions attempted. No other documentation was provided of any toileting schedule attempted during Resident R139's admission. No documentation was provided on offering Resident R139 a bedpan or commode (bedside portable toilet).

A facility policy on toileting programs was request but not received.

Facility's policy titled Bowel (Lower Gastrointestinal tract) Disorders - Clinical protocol dated 9/2017, indicated as part of the initial assessment, the staff and physician will help identify individuals with previously lower gastrointestinal tract conditions and symptoms. Policy also indicated the nurse shall assess and document/report abdominal assessment, all current diagnosis, all current medications, active diagnosis, and recent labs. Further, the policy indicated the staff and physician will identify risk factors related to bowel dysfunction; for example, severe anxiety disorder, use of medications that are used to treat, or may cause or contribute to gastrointestinal erosion, bleeding, diarrhea, dysmotility, etc. Furthermore, the policy indicated

the staff and physician will characterize symptoms related to bowel function, for example, time relationship to meals, presence of cramps and bloating, etc.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 34 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49034 potential for actual harm Based on interview and document review, the facility failed to ensure an antibiotic without an end date was Residents Affected - Few monitored and evaluated for the appropriateness of its continued use for 1 of 1 residents (Resident R107) reviewed for antibiotic administration.

Findings include:

Resident R107's quarterly Minimum Data Set (MDS) dated [DATE REDACTED], indicated Resident R107 had intact cognition, no wound infection, and had a hip fracture. The MDS indicated Resident R107 was taking an antibiotic.

Resident R107's order summary dated 12/6/24, indicated Resident R107 was taking 500 milligrams (mg) of cephalexin (an antibiotic) four times a day for infections starting on 12/6/24 with no end date.

Resident R107's hospital note dated 12/6/24, indicated Resident R107 was admitted to the hospital on 12/3/24, had a planned hip surgery, and was discharged back to the facility on [DATE REDACTED]. The note indicated Resident R107 was to follow up with the orthopedic trauma clinic in two weeks but could call the office before that time with any additional questions or concerns.

Resident R107's hospital discharge orders dated 12/6/24, indicated Resident R107 was to take 500 milligrams of cephalexin four times a day for prophylaxis for a closed hip fracture. The order did not indicate when the medication when the medication was to be discontinued.

Resident R107's Antibiotic Time Out dated 12/6/24, indicated physician's assistant (PA)-A (the facility provider) had ordered 500 milligrams of cephalexin four times a day. The document indicated, under the evaluate the antibiotic section, that PA-A was notified of Resident R107's current clinical status and the current antibiotic order was reviewed with PA-A who indicated Resident R107 should continue with current antibiotic therapy. The document section titled verify the total length of antibiotic treatment had other selected with no further indication of what

the total length of antibiotic treatment should have been.

Resident R107's orthopedic clinic note dated 12/17/24, indicated Resident R107 had been seen by the orthopedic provider but did not mention or include further instructions regarding antibiotic use.

Resident R107's progress note dated 12/17/24 at 1:20 p.m., indicated Resident R107 had her staples removed at the orthopedic clinic appointment and the hip incision looked dry with no s/s [signs/symptoms] of infection.

Resident R107's medical record was reviewed and did not indicate when or if the Cephalexin was to be discontinued.

During an interview on 1/6/25 at 12:59 p.m., Resident R107 stated she was on an antibiotic because of her hip surgery. Resident R107 stated she didn't think she had an infection and thought the antibiotic should have been stopped previously but staff kept bringing it to her, so she kept taking it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 34 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 0757 During an interview on 1/9/25 at 7:56 a.m., the infection control preventionist (IPCP) stated the facility got in touch with the orthopedic provider team who had ordered the antibiotic yesterday. The IPCP stated the Level of Harm - Minimal harm or orthopedic provider told them to discontinue the antibiotic immediately as it was only supposed to be given potential for actual harm for 18 days. The IPCP stated a case was supposed to be created for antibiotic tracking but as this had not happened, they had missed the medication did not have a stop date. The IPCP stated it was important Residents Affected - Few residents are not given antibiotics longer than necessary as this can weaken their immune system and make them more likely to have infections such as C. diff (Clostridioides difficile, an infection of the colon causing extensive diarrhea).

During an interview on 1/9/25 at 11:27 a.m., PA-A stated he had not been the ordering provider for the cephalexin, this had been ordered by the hospital on 12/6/24. PA-A stated he had not been notified by the facility that Resident R107 had been started on this antibiotic otherwise he would have ensured there was a stop date. PA-A stated that Resident R107's daily dose of cephalexin was higher than a usual prophylactic dose making it even more important that it was discontinued. PA-A stated he would have expected the facility to reach out to him or the hospital when they first saw the order so an end date could have been determined.

The facility's Antibiotic Stewardship policy dated 10/4/21, indicated the facility would review antibiotic utilization, as part of antibiotic stewardship, for specific situations that are not consistent with the appropriate use of antibiotics. The policy indicated at the conclusion of this review, the provider would be notified of

review findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 34 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 0773 Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47495

Residents Affected - Few Based on interview and document review, the facility failed to ensure an order for laboratory services was followed through and completed for 1 of 1 resident (Resident R145) reviewed for laboratory services who had Clostridium difficile (C. diff; bacteria which can cause diarrhea, abdominal pain and cramping, fever, nausea, and dehydration.)

Findings include:

Resident R145's significant change Minimum Data Set (MDS), dated [DATE REDACTED], indicated Resident R145 was admitted to the facility on [DATE REDACTED], was cognitively intact and required substantial/maximum assistance with toileting and partial to moderate assistance with personal hygiene.

Resident R145's Orders contained two orders to test for C-diff, one dated 12/16/24 and another dated 12/31/24.

On 12/17/24, it was documented in Resident R145's progress notes, Collected stool specimen, called lab for pick up today.

On 12/30/24, it was documented in Resident R145's progress notes that Resident R145 continued to report having 4-9 stools daily.

On 12/30/24, it was documented in Resident R145's progress notes that the lab informed that previous C-diff rest was incorrectly collected. New order placed to complete C-diff stool test again due to ongoing frequent BMs [bowel movements]/diarrhea.

On 1/5/25, it was documented in Resident R145's progress notes that Resident R145 tested positive for C-diff.

During an interview on 01/06/25 at 5:41 p.m., Resident R145 stated she had been having diarrhea for about a month, stating she was unable to control her bowel movements because of the frequency and urgency of her bowel movements. Resident R145 stated she was supposed to start an antibiotic for C-diff tomorrow.

During an interview on 1/9/24 at 9:04 a.m., licensed practical nurse (LPN)-C stated if there was an order to collect a specimen, it would be an order placed on the MAR, the nurse would call the lab to see how best to collect the specimen and it would be collected as soon as possible. LPN-C stated the lab would then be called to pick up the specimen. LPN-C stated she was unsure of the process if results were not received from the lab.

During an interview on 1/9/25 at 9:20 a.m., hospice registered nurse (RN)-I stated he had ordered the original test for C-diff back on 12/16/24. RN-I stated he rewrote the order for the c-diff test on 12/30/24 when

he noticed the results had not been received from the lab and due to Resident R145's ongoing diarrhea.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 34 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 0773 During an interview on 1/9/25 at 9:25 a.m., clinical nurse manager and RN-C stated the initial stool specimen for Resident R145's c-diff test was collected in the wrong container, and it would have been expected for the nurses to Level of Harm - Minimal harm or follow up with the lab in 24-48 hours after not receiving results. potential for actual harm

During an interview on 1/9/25 at 11:10 a.m., the director of nursing (DON) stated when an order was Residents Affected - Few received that required a specimen to be collected, it was expected that nursing staff collect the specimen as soon as possible, watch for the lab results to be returned and follow up with the lab if no results are received.

The DON confirmed she would have expected the nursing staff to follow up with the lab after the specimen was sent to the lab on 12/17/24 and no results were recieved to ensure quicker testing and treatment for Resident R145.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 34 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 0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49034

Residents Affected - Few Based on observation, interview, and document review, the facility failed to provide the ordered drink consistency for 1 of 1 residents (Resident R82) reviewed for dining.

Findings include:

Resident R82's admission Minimum Data Set (MDS) dated [DATE REDACTED], indicated Resident R82 had intact cognition with diagnoses of heart failure, kidney disease, and malnutrition. The MDS indicated Resident R82 required setup help with eating.

Resident R82's progress note dated 12/31/24 at 1:07 p.m., indicated Resident R82 had declined in status upon hospital return and the speech therapist recommended a diet change to a pureed texted and nectar thick liquids.

Resident R82's care plan dated 1/3/25, indicated Resident R82 had a diagnosis of dysphagia and a 12/24 diagnosis of Respiratory Syncytial Virus (RSV) and pneumonia.

Resident R82's order summary report dated 1/6/25, indicated Resident R82 was on a mechanical soft (soft easy to chew and swallow foods) textured diet with all liquids thickened to a nectar consistency.

Resident R82's Speech Therapy Treatment Encounter Note dated 1/7/25, indicated Resident R82 was being seen by speech-language pathologist (SLP)-A for a session targeting swallowing. SLP-A attempted a thin water trial that resulted in a frequent wet vocal quality that was cleared given max verbal cues from SLP-A.

During an observation and interview on 1/8/25 at 10:31 p.m., Resident R82 was observed sitting at a table in the dining room with a glass of water with ice and a mug that appeared filled with black coffee. Resident R82 had no menu or meal ticket observed on the table. Nursing assistant (NA)-A was observed pouring Resident R82 orange juice and milk. NA-A was then observed moving to the next table and pouring drinks for other residents.

During an interview and observation on 1/8/25 at 10:36 a.m., NA-A was interviewed and stated he would check the meal slip that was given to each resident with their meal to see what consistency of liquids was needed. NA-A acknowledged that when he passed liquids before meals were delivered to residents, he did not have the meal slips to reference but knew based on memory what residents could have non-thickened liquids. NA-A stated that Resident R82 could have non-thickened liquids and confirmed the liquids he had given Resident R82 were not thickened. Resident R82 was then observed to take a large drink of orange juice and immediately proceeded to cough a wet-sounding cough.

During an interview and observation on 1/8/25 at 10:43 a.m., the director of nursing (DON) confirmed Resident R82 was supposed to receive nectar-thick liquids per his orders. The DON stated she had examined Resident R82's liquids and she was unsure if the orange juice was thickened or not but the water, coffee, and milk, did not appear to be. The DON was observed removing the liquids from Resident R82's table.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 34 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 0805 During an interview on 1/8/25 at 10:55 a.m., with SLP-A, dietician (D)-A, and the DON, SLP-A stated she had trialed non-thickened liquids with Resident R82, but she continued to recommend he receive nectar thick liquids as Level of Harm - Minimal harm or ordered. The DON stated the nursing assistants should use the meal tickets to see what consistency the potential for actual harm liquids should be. The DON stated if it was before meal service, the aides could use a report with all resident's diets on it, but she didn't usually see this used other than when snacks were passed between meal Residents Affected - Few services. At 11:56 a.m., the DON confirmed the facility had completed an audit and all residents were receiving liquids of the correct consistency for resident safety, and staff were educated on where to find this information.

The facility's Therapeutic Diet policy dated 12/29/21, indicated a therapeutic diet, including a mechanically altered diet, would be prescribed to a resident to support the resident's treatment and plan of care in accordance with his or her goals and preferences.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 34 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 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** 44656 potential for actual harm Based on observation and interview the facility failed to follow infection control standards of practice for the Residents Affected - Few cleaning of hard surfaces in the resident room for 1 of 1 residents (Resident R39) on enhanced barrier precautions (EBP) reviewed for infection control practices.

Findings include:

According to the Centers for Disease Control (CDC) March 19, 2024, article titled Healthcare-Associated Infections (HAIs), the cleaning of patient care areas includes, Potential for exposure to pathogens: High touch surfaces (e.g., bed rails) require more frequent and rigorous environmental cleaning than low-touch surfaces (e.g., walls).

The CDC article titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) dated 4/2/24, indicated MDRO transmission in skilled nursing facilities was common and contributed to substantial resident morbidity. EBP is an infection control intervention to reduce transmission of MDROs by using gowns and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing that lead to indirect transfer of MDROs from resident to resident. The article indicated EBP should be implemented (when contact precautions did not apply) for residents who are high risk for acquiring infections with wounds or indwelling medical devices (central lines, urinary catheter, feeding tube, and ventilator dependent) regardless of MDRO colonization status.

Resident R39's quarterly Minimum Data Set (MDS) dated [DATE REDACTED], identified Resident R39 with severe cognitive impairment, did not reject care, 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, pneumonia, and chronic obstructive pulmonary disease (damaged lungs that limit airflow in and out of lungs). In addition, Resident R39 was documented as at risk for pressure ulcers, had one stage two 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.

During observation on 1/6/25 at 1:29 p.m., the door frame to resident room had a posted Enhanced Barrier Precautions (EBP) sign and a personal protective equipment (PPE) cart outside resident room.

During observation and interview with LPN-A on 1/8/25 at 8:51 a.m., LPN-A pointed to Resident R39's black foam-covered side rails and identified, [Resident R39's] coverings [are] shredded and broken in appearance so that

the metal portion of the side rails is present of visible. Also, the foam was taped to portions of the side rail with thick black tape or duct tape.

During observation and interview on 1/8/25 at 2:10 p.m., with licensed practical nurse (LPN)-A, LPN-A looked at Resident R39 side rails and stated, [those] black coverings have been here forever. LPN-A stated she was unaware of when they were applied to Resident R39's side rails and verified, they look shredded and shabby. LPN-A was unable to describe if or how Resident R39's side rails were able to be cleaned and disinfected.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 34 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 0880 During observation and interview with RN-A on 1/8/25 at 2:14 p.m., RN-A looked at Resident R39 side rails and stated, [they are] peeling. They have been on there since I have been here [several months]. And, pointing to Level of Harm - Minimal harm or the foam-covered side rails, Disrepair [in appearance]. Not sanitary. Could not clean that because it is frayed potential for actual harm and porous. RN-A unable to describe if or how Resident R39's side rails were able to be cleaned and disinfected.

Residents Affected - Few During interview with infection control preventionist (IPCP) on 1/8/25 at 2:29 p.m., ICPC stated regarding the siderail padding, it is a pool noodle to help cushion [Resident R39] skin from hitting it. Yes, it should be replaced. It is unable to be cleaned appropriately. [Resident R39] is vulnerable and on EBP. Not sanitary to be able to clean it.

During interview with housekeeper (HK)-C on 1/8/25 at 1:46 p.m., HK-C stated the expectation of housekeepers was to clean, all hard surfaces in resident rooms daily, including side rails.

During interview with HK-A on 1/8/25 at 1:57 p.m., HK-A stated the expectation of housekeepers was to wipe

the side rails of resident rooms daily.

During observation and interview with HK-B on 1/8/25 at 2:00 p.m., HK-B stated she was assigned to clean Resident R39's room daily. HK-B stated the expectation was to clean, side rails too. I can't ensure the cover to the side rail [pointing to the black foam covering] can be cleaned. HK-B pointed to black foam covering of Resident R39's side rails, not in good condition verifying black strapping tape or duct tape used to wrap/secure the foam to

the side rail. Also, HK-B stated she, cannot confirm I ever tried to wipe that down. During interview with HK-B

on 1/9/25 at 10:36 a.m., HK-B stated the expectation was housekeeping, look at the yellow sign [EBP] posted outside the door [to inform all staff of what to do when entering resident room].

Facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment, reviewed 10/18/2022 state, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection. The policy identified, non-critical environmental surfaces [to] include bed rails.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 34 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.

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 door would be left open for such. DON responded, No, I don't, and identified the one staff member in the 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 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 34 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 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 Level of Harm - Minimal harm or door open at all times, unless changing brief. In addition, a subsequent section outlined, ADL self care potential for actual harm 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 Residents Affected - Some 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.

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 privacy regarding . b. medical treatment . d. personal care.

44656

EXPOSED RESIDENT INFORMATION:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 34 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 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 Level of Harm - Minimal harm or preferences, physical and food assistance needs. The facility was under construction with six contracted potential for actual harm flooring employees installing laminate flooring in the second floor hallway where the unattended medication cart was located. Residents Affected - Some

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

f. family and resident group meetings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 34 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 0638 Assure that each resident’s assessment is updated at least once every 3 months.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33925 potential for actual harm Based on interview and document review, the facility failed to ensure a quarterly Minimum Data Set (MDS) Residents Affected - Few was completed in a timely and/or comprehensive manner to facilitate accurate evaluation of resident' conditions for 2 of 3 residents (Resident R50, Resident R108) reviewed for MDS accuracy.

Findings include:

Resident R50

The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument 3. 0 User's Manual, dated 10/2023, identified the RAI process (i.e., MDS) was completed to help evaluate resident' strengths and areas for care-planning. The manual listed all types of assessments to be completed along with corresponding timeframe's for them via a graph labeled, RAI OBRA-required Assessment Summary. This directed a quarterly MDS should be completed (i.e., signed) within, ARD + 14 calendar days.

Resident R50's significant change MDS, dated [DATE REDACTED], identified Resident R50 had severe cognitive impairment, demonstrated hallucinations, and was on hospice.

Resident R50's electronic medical record listed a section labeled, MDS, which listed every completed MDS to date for Resident R50. A subsequent quarterly MDS, with an assessment reference date (ARD) 12/24/24, was listed but categorized as, In Progress. The MDS was not completed with multiple sections being red-colored and having little or no data entered and being labeled, In Progress. The uncompleted sections included, Hearing, Speech and Vision, and, Behavior, and, Bladder and Bowel, among several others.

Resident R50's medical record was reviewed and lacked evidence why the MDS had not been completed timely per

the RAI manual (due 1/7/25).

When interviewed on 1/8/25 at 1:07 p.m., registered nurse (RN)-F verified they help complete the MDS for

the campus. RN-F verified Resident R50's quarterly MDS was not finished and should have been within 14 days of the ARD adding, We haven't gotten to it yet. RN-F stated the corresponding assessments for the sections (i.e., pain assessments, bladder assessments) didn't seem to be finished in the record, either, which would likely cause many sections on the MDS to be dashed as 'not assessed' adding aloud, It will unfortunately.

Resident R108

The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument 3. 0 User's Manual, dated 10/2023, identified the RAI process (i.e., MDS) was completed to help evaluate resident' strengths and areas for care-planning. The manual outlined all sections of the MDS to be completed and listed, C: Cognitive Patterns, as used, Determine the resident's attention, orientation, and ability to registered and recall information, and whether the resident has signs and symptoms of delirium. Further, it listed, D: Mood, as used, Identify signs and symptoms of mood distress and social isolation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 34 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 0638 Resident R108's quarterly MDS, dated [DATE REDACTED], identified the MDS was signed as completed. However, the sections labeled, Section C - Cognitive Patterns, and, Section D - Mood, had all their respective answers (sections Level of Harm - Minimal harm or used to evaluate the resident) dashed as, - Not assessed, or, - Not assessed/no information. potential for actual harm Resident R108's medical record was reviewed and lacked evidence why the MDS had not been completed in a Residents Affected - Few comprehensive manner to accurately evaluate Resident R108's cognition or mood symptoms.

When interviewed on 1/7/25 at 1:29 p.m., RN-F verified the MDS was coded correctly, however, it was coded as 'not assessed' due to the corresponding assessments (i.e., BIMS, PHQ-9) not being completed. RN-F stated the social services department was responsible to complete those and then the captured data gets transferred to the MDS. RN-F stated they felt the assessments, and subsequently the sections of the MDS, not being completed thoroughly was kind of an outlier. However, RN-F stated it was important to ensure the MDS was thoroughly completed as it helped showed the most accurate picture of the resident.

A provided MDS Completion and Submission Timeframes policy, dated 4/2023, identified the care center would complete and submit assessments in accordance with federal and state timeframe's. The policy outlined, Timeframes for completion and submission is based on the current requirements published in the [RAI] manual.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 34 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 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48065

Residents Affected - Few Based on interview, observation and document review, the facility failed to ensure comprehensive care plans were developed and maintained to facilitate person-centered care for 2 of 2 (Resident R142, Resident R139) residents reviewed for care planning.

Resident R142

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 Resident R142 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.

Resident R142's Clinical Orders report, printed on 1/8/25, did not include any orders related to Resident R142's right prosthetic leg.

Resident R142's care plan printed on 1/8/25, included a Functional Restorative Plan, Activities of Daily Living (ADLs), and Risk for falls.

The Functional Restorative Plan indicated limited mobility, weakness. The goal indicated resident will improve in ambulation. The interventions indicated walking activity: ambulate with assistance of 1 using walker in hallway.

The ADL care plan's goal indicate the resident will maintain the current level of function on ADL's. The intervention dated 10/16/24 for ambulation indicated the resident requires extensive assistance by 1 staff to walk with walker in room and between surfaces with a revision date of 12/28/24.

The fall risk's care plan indicated Resident R142 was at risk for falls r/t being BKA(R) [below the knee amputation-right leg]. The goal indicated Resident R142 will be free of falls. Interventions indicated anticipation of needs and placement of call light within reach.

All these care plans failed to indicate Resident R142 had a prosthetic leg.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 34 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 0656 During observation and interview on 1/7/25 at 1:51 p.m., Resident R142 was sitting on his recliner watching television. Resident R142 stated the staff doesn't know how to put on my prosthetic leg. Nobody knows what they are doing, only Level of Harm - Minimal harm or two nursing assistants (NA) know what to do. They [NA] have not been trained. I need to tell them what to potential for actual harm do. Resident R142 stated he was supposed to ambulate in the hallway twice a day with a NA, but it was not done, unless one of the two NA (mentioned before) were working. Residents Affected - Few

During interview on 1/7/25 at 2:38 p.m., NA-D stated Resident R142's Kardex didn't mention his prosthetic leg, but he was trained by the therapist. NA-D stated he believed all staff members were trained how to put the prosthetic leg on and off.

During interview on 01/07/25 at 3:17 p.m., nursing assistant (NA)-E stated she didn't know how to put on Resident R142's prosthetic leg. NA-E stated Resident R142's Kardex did not have any information about his prosthetic leg.

During interview on 1/8/25 at 9:00 a.m., nurse manager/registered nurse (RN)-C verified there was no mention of Resident R142's prosthetic leg in his physician orders, care plan or Kardex. RN-C stated NA-D, registered nurse (RN)-E, licensed practical nurse (LPN)-D and herself were trained by the physical therapist. RN-C stated all the staff was trained. RN-C stated the therapist trained all the nursing assistants.

During interview on 1/9/25 at 11:25 a.m., physical therapist (PT)-A stated she demonstrated to RN-C and NA-D how to put on the prosthetic leg. PT-A stated she only trained those two people, and stated nobody else was trained. PT-A stated the nurse managers were supposed to train all the staff that works with Resident R142. PT-A stated Resident R142 received his leg when he was in the facility's transitional care unit. Resident R142 needed to follow

a progressive schedule to wear his orthopedic leg, but Resident R142 offered various reasons why he didn't follow the progressive schedule. PT-A stated Resident R142 should had been able to wear his prosthetic leg the whole day

before he was discharged from therapies and moved to the long-term care unit.

During interview on 1/8/25 at 1:04 p.m., director of nursing (DON) verified Resident R142's physician orders, care plan, Kardex, and medication/treatment administration record failed to mention Resident R142's prosthetic leg. DON stated, she expected the care plan was updated because it was important for the staff to know how to care for the resident and how to put on and care for his prosthetic leg.

49339

Resident R139

Resident R139's quarterly Minimum Data Set (MDS), dated [DATE REDACTED], identified Resident R139 was cognitively intact with no hallucinations or delusions. Diagnoses included: cerebral infarction (also known as an ischemic stroke; occurs when blood flow to the brain is blocked, causing the brain tissues to die), hypertension (high blood pressure), diabetes (a disease that occurs when you blood glucose is too high), arthritis, multiple sclerosis (disease that causes breakdown of the protective covering of the nerves that can result in numbness, weakness, trouble walking, vision changes and other symptoms), anxiety, depression, dysphagia (swallowing disorder), hemiplegia (paralysis that affects one side of the body) and fibromyalgia (condition that involves widespread body pain and tiredness). In addition, Resident R139 was dependent on staff for transfers and mobility, and required maximal assistance from staff for dressing, personal hygiene and eating.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 34 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 0656 During interview on 1/06/25 at 1:12 p.m., Resident R139 stated she can sense when she has to urinate and stated she would like to be able to use the toilet instead of going in her incontinence pad. Resident R139 stated staff do not offer Level of Harm - Minimal harm or to bring her to the bathroom to use the toilet and this would be her preference. potential for actual harm

During a follow up interview on 1/09/25 at 9:41 a.m., Resident R139 was observed lying in bed. Resident R139 once again, Residents Affected - Few expressed a desire to be able to use the toilet. Resident R139 stated, I don't like to go in my underwear. Resident R139 stated most of the time she can feel when she has to urinate. Resident R139 stated staff do not offer to bring her to the bathroom or to use a bedpan [a device used as a receptacle for the urine and/or feces of a person who is confined to a bed] and added they just change my pad. Resident R139 stated she feels confident that she can sit on

the toilet with support as she has been working with physical therapy for a long time. Resident R139 stated, they offered me a bedpan a long time ago, which wasn't the best, but they don't even offer that let alone the toilet. Resident R139 indicated that staff transfer her with a Hoyer lift [mechanical lift/device that lifts patients from one place to another who cannot bear weight on their lower extremities] and physical therapy use a EZ stand [manual standing aid to allow patients to assist themselves in preparation for transferring] to transfer her.

Resident R139's care plan, printed 1/9/25, identified the following:

- TRANSFER: Resident requires assist x2 Standing Lift.

- TOILET USE: Resident requires extensive assist x 1 staff.

- The resident is incontinent of bladder Impaired Mobility

- BRIEF USE: The resident uses disposable briefs. Change per schedule and prn.

- INCONTINENT: Check (with cares every AM, PM, Before or after meals and on first and third rounds at night and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes.

Resident R139's care plan lacked evidence of coordination between providers (facility and therapy). Additionally, Resident R139's care plan lacked evidence of Resident R139's preference to use the toilet. Additionally, Resident R139's care plan lacked evidence of Resident R139's fluctuating ability in transfers.

Resident R139's Kardex, printed 1/8/25, indicated the following:

-TOILET USE: Resident requires extensive assist x1 staff.

-TRANSFER: Resident requires assist x2 Standing lift.

On 1/07/25 at 3:50 p.m., nursing assistant (NA)-B stated they are familiar with Resident R139. NA-B indicated Resident R139 needs assist of 2 staff and a mechanical lift for all transfers. Furthermore, Resident R139 was incontinent of bowel and bladder. NA-B stated they know of Resident R139 using the bedpan once previously, about 2-3 months ago but not since. NA-B stated they do not offer to put Resident R139 on the toilet and just provide incontinent cares for Resident R139. NA-B indicated that Resident R139 was able to identify when she needs incontinent cares completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 34 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 0656 On 1/08/25 at 12:34 p.m., NA-A verified they are familiar with Resident R139 and indicated Resident R139 was on incontinence checks. NA-A indicated they have not offered Resident R139 to use the toilet or the bedpan. NA-A verified they refer Level of Harm - Minimal harm or to the Kardex for resident needs. NA-A stated they are unsure how Resident R139 transfers. After reviewing the potential for actual harm Kardex, NA-A indicated the Kardex indicated Resident R139 transfers with assist of 2 staff and an EZ Stand (standing mechanical lift)/standing lift. NA-A indicated they are trained to follow the Kardex on resident needs. Residents Affected - Few

On 1/08/25 at 12:59 p.m., licensed practical nurse (LPN)-E indicated Resident R139 required total staff assistance.

After reviewing Resident R139's care plan, LPN-E indicated Resident R139 transfers with assist of 2 staff and EZ Stand/standing lift.

On 1/08/25 at 1:11 p.m., registered nurse (RN)-C verified they are familiar with Resident R139. RN-C indicated Resident R139 transfers with an EZ stand/standing lift and assist of 2 staff. RN-C indicated Resident R139 was incontinent of bowel and bladder. RN-C indicated they attempted to transfer Resident R139 to use the toilet but unable to recall when. RN-C indicated they offered Resident R139 the use of the bed and indicated that was more than 6 months ago. RN-C indicated they would look for documentation regarding this.

During a follow up interview on 1/08/2025 at 2:40 p.m., RN-C indicated they could not find any documentation around offering the use of the toilet or bedpan. RN-C indicated, most cognitively intact people want to use the toilet.

On 1/08/25 at 1:30 p.m., physical therapist (PT)-A verified Resident R139 currently receiving physical therapy services and was discharged from occupational therapy services on 12/20/24. PT-A stated, Generally speaking, if someone is able to sue an EZ-Stand [manual standing aid to allow patients to assist themselves in preparation for transferring], they can use a toilet, maybe not be left alone. PT-A verified during Resident R139's last PT session, Resident R139 transferred with an EZ stand/standing lift with moderate assistance.

On 1/09/25 at 9:52 a.m., licensed practical nurse (LPN)-C indicated Resident R139 transfers with a mechanical lift. LPN-C indicated they were unsure if Resident R139 was offered the bedpan or toilet. LPN-C indicated Resident R139 was on scheduled to have her incontinent pad check and changed.

On 1/09/25 at 10:05 a.m., NA-C indicated Resident R139 transfers with a Hoyer lift and assist of 2 staff and Resident R139 does not use a bedpan or the toilet. NA-C indicated Resident R139 will ask to be changed when needed as Resident R139 was able to identify when they need to be changed. NA-C verified they have not offered Resident R139 the bedpan or the use of the toilet.

On 1/09/25 at 10:56 a.m., PT-B verified Resident R139's last physical therapy was 1/6/24 and used the EZ stand. PT-B indicated, I don't know why that would be a problem if they can sit safely on the toilet, when asked about a resident using a toilet when transferring with a mechanical lift. PT-B indicated part of the physical therapy goal is using the EZ stand with staff.

On 1/09/25 at 1:34 p.m., physical therapy assistant (PTA)-A verified they are familiar with Resident R139. PTA-A verified Resident R139 transfers with an EZ stand and indicated there have been no updates sent to nursing in 6-12 months, on recommendations changing how Resident R139 transfers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 34 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 0656 On 1/09/25 at 1:55 p.m., director of nursing (DON) verified nursing staff would look at the care plan/Kardex for resident needs (how they transfer, preferences, etc.). DON verified Resident R139's care plan indicated Resident R139 Level of Harm - Minimal harm or transfers with assist of 2 staff and EZ stand/standing lift. potential for actual harm

A facility policy titles Care Plans, Comprehensive Person-Centered, reviewed 11/30/21, indicated Residents Affected - Few comprehensive, person -centered care plans will:

- reflect the resident's expressed wishes regarding care and treatment goals

- aid in preventing or reducing decline in the resident's functional status and/or functional levels

Facility policy titled Care Plans, Comprehensive Person-Centered reviewed 11/30/21, also indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 34 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33925 potential for actual harm Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene Residents Affected - Few cares (i.e., nail care) was completed to reduce the risk of complication (i.e., scratches, infection) for 1 of 3 residents (Resident R47) reviewed for activities of daily living (ADL) and whom was dependent on staff for their nail care.

Findings include:

Resident R47's admission Minimum Data Set (MDS), dated [DATE REDACTED], identified Resident R47 had severe cognitive impairment and demonstrated no rejection of care behaviors during the review period. Further, the MDS outlined Resident R47 was dependent on staff for bathing, and required supervision or touching assistance with personal hygiene (i. e., shaving, combing hair).

Resident R47's most recent Weekly Bath Audit 020919 - V9, dated 1/2/25, identified Resident R47 received a bed bath. The audit listed, Was nail care rendered? which was answered, 1. Yes. The audit also listed, Are nail beds clear of debris? which was answered, 1. Yes. Further, the audit outlined, Patient has scratches on his left side of his glute, patient states that he scratched himself recently.

However, on 1/6/25 at 2:01 p.m. (four days later), Resident R47 was observed lying in bed while in his room. Resident R47 was dressed in a hospital-gown and was unable to recall what, if any, meal had been served for lunch nor how long he had been at the care center. Resident R47's hands were visible and Resident R47 had several nails on both hands, especially the thumb nails, which were multiple millimeters (mm) in length. Further, multiple nails had visible brown or black-colored debris present under them. Resident R47 was questioned on his nails and held his hands up to look at them, however, had no verbal response on them. When asked if he'd like them clipped shorter or cleaned, Resident R47 responded aloud, Yea.

Resident R47's care plan, dated 12/4/24, identified Resident R47 was non-ambulatory due to an ankle fracture and outlined, Resident performance: Personal hygiene - Supervision/set-up help only. Further, the care plan outlined a section labeled, ADL self care needs ., which outlined, AM ROUTINE . - Dependent dressing. The care plan lacked any outlined nail length preference for Resident R47 (i.e., long or short), nor evidence Resident R47 was identified to refuse nail care.

On 1/7/25 at 8:31 a.m., Resident R47 was again observed while in his room. Resident R47 continued to have the same long, soiled nails and nail beds as had been observed the day prior. Further, the following day on 1/8/25 at 8:23 a. m., Resident R47 was again observed to have the same length fingernails including multiple ones with debris present underneath of them.

Resident R47's medical record was reviewed and lacked evidence Resident R47 had nail care offered or provided despite being observed for multiple days with continued long, soiled nails and/or nail beds.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 34 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 0677 On 1/8/25 at 10:04 a.m., nursing assistant (NA)-F was interviewed. NA-F verified they were assigned care for Resident R47 and had worked with him multiple times prior. NA-F described Resident R47 as needing staff assistance with all Level of Harm - Minimal harm or cares except feeding adding, We do everything for him. NA-F stated Resident R47 was generally accepting of cares potential for actual harm and mostly just wanted to go back home. NA-F explained baths were done weekly and the nurses will help with nail care, if needed. At 10:07 a.m., NA-F observed Resident R47's nails and verified their length and condition Residents Affected - Few adding aloud, They need to be trimmed. NA-F stated the nails were kind of longer and [he] could scratch himself. Resident R47 was asked if he'd like them clipped and responded, Yea. NA-F stated the nails should be clipped on bath day adding they were unaware of any preference for Resident R47 to have longer, soiled nails.

When interviewed on 1/8/25 at 10:57 a.m., registered nurse (RN)-H stated nail care should be completed every bath day and, if the resident is not diabetic, then the NA can do it. RN-H stated each bath is done by

the NA and the nurse then should follow-up afterward to ensure the list of things they do are done, including nail care. RN-H verified nail care could be completed in-between assigned bath days, too, if noticed it was needed. RN-H stated they were assigned care for Resident R47 that day, however, had not noticed his nails being long adding, I will look at it later. RN-H verified Resident R47 was not diabetic and was generally accepting of care. Further, RN-H stated any attempt to do nail care should be documented in the notes.

On 1/8/25 at 11:55 a.m., the director of nursing (DON) was interviewed. DON verified nail care should be completed on assigned bath days but would also be done in-between if noticed. DON added, I do expect nurses to verify the charting is done.

A provided Fingernails/Toenails, Care of policy, dated 2/2022, identified a procedure to ensure nail care was done adding, Nail care includes daily cleaning and regular trimming. The policy included, Proper nail care can aid in the prevention of skin problems around the nail bed. Further, the policy directed nail care, when done, should be documented in the medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 34 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 0679 Provide activities to meet all resident's needs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33925 potential for actual harm Based on interview, and document review, the facility failed to comprehensively reassess and, if needed or Residents Affected - Few able, develop interventions to ensure activities-of-interest were advertised, offered and/or provided for 1 of 2 residents (Resident R222) reviewed for activities and whom resided on the short-term unit (i.e., TCU).

Findings include:

Resident R222's admission Minimum Data Set (MDS), dated [DATE REDACTED], identified Resident R222 had intact cognition and demonstrated no delusional thinking. The MDS outlined several questions with a response of importance to Resident R222, including having reading materials, keeping up with the news, and doing her favorite activities. These were all coded with a response of, Somewhat important, or, Very important.

Resident R222's Therapeutic Recreation/Activity Evaluation, dated 11/27/24, identified Resident R222's background information along with a section labeled, Recreation Interest/Needs, which contained checkmarks placed next to applicable items. These outlined Resident R222 liked activities in groups, independently, in her room or day room, and marked her participation as, Independent/individual. The evaluation outlined Resident R222's current interests as, television, music (rock), getting rest, card making, making Victorian ornaments, beading, family phone calls, and also outlined Resident R222 needed assistance to get to/from activities areas. The evaluation concluded with a section labeled, Summary, which outlined, . plans on short stay and to return home. At this time she states

she is not in the 'mood' to do anything, discouraged with health status. When she starts feeling better, she stated she may enjoy engaging in activities offered . Proceed to plan of care. The completed evaluation lacked what, if any, in room options for doing her identified interests were offered or provided (i.e., craft material, beads).

On 1/6/25 at 12:54 p.m., Resident R222 was interviewed while in her room on the TCU. Resident R222 explained she had admitted in November 2024 and, upon admission, was non-weight bearing due to a boot placed on her leg adding, [it was] very difficult for me to get around, period. Resident R222 stated she had not been attending much, if any, activities and explained it was due to multiple reasons including her immobility and feeling, at times, it was more depressing to be around elderly, confused people. Resident R222 stated she knew there were some activities offered but didn't know what they were as there was no calendar posted in her room. Resident R222 stated, I think there is one somewhere [posted] but not in here. Resident R222 explained she was now no longer non-weight bearing and would be more open to activities, if offered, however, she stated nobody ever came and offered any activities to her, either, which she voiced, I would be receptive to that. Resident R222 stated she recalled going to

a music program once since admitting which was around Christmas adding, That was nice.

Resident R222's care plan, dated 12/12/24, identified Resident R222 was able to verbalize her preferences and was independent in meeting her emotional, intellectual, social and physical needs. The care plan outlined a single intervention for this which read, Resident enjoys participating in their favorite activities - getting rest, watching television, card making, making Victorian ornaments, beading . The intervention was initiated and last revised both on 11/27/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 34 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 0679 When interviewed on 1/7/25 at 11:56 a.m., nursing assistant (NA)-G stated they worked with Resident R222 over the past weekend along with stray lights here and there. NA-G stated Resident R222 rarely left her room or attended Level of Harm - Minimal harm or activities adding, Not really. NA-G stated they felt the lack of attendance with activities was her choice potential for actual harm adding, I think she keeps herself busy. NA-G stated the TCU did have a posted activities calendar outside

the main elevators adding sometimes each resident' room will have them but they hadn't ever seen one in Residents Affected - Few Resident R222's room to their recall. NA-G stated nobody had directed them to ever offer activities or go through the calendar with her adding, Not specifically to her, no.

Resident R222's progress note, dated 12/11/24, identified Resident R222 was advanced to weight-bearing as tolerated (WBAT) with use of the PRAFO boot; and on 12/20 could be WBAT without it applied.

Resident R222's activity attendance was requested. A provided Follow Up Question Report, printed 1/7/25, identified Resident R222's recorded activities, level of participation and the corresponding date of each. This record identified Resident R222 attended or had provided only four activities since admission to the care center in November 2024.

These included:

On 12/4/24, a chaplain visit was recorded with Resident R222 having active participation.

On 12/22/24, a music group was recorded with Resident R222 having active participation.

On 12/24/24, a party or special event along with friend/family visits were recorded with Resident R222 having active participation.

Resident R222's medical record was reviewed and lacked any evidence Resident R222 had been comprehensively reassessed to determine what, if any, activities needs were needed to promote quality of life despite Resident R222 rarely attending services and having healed with no longer being non-weight bearing. There was no evidence what, if any, in-room activities were offered or provided despite Resident R222 expressing interest in such when assessed upon admission.

On 1/8/25 at 12:32 p.m., the therapeutic recreation coordinator (TRC) and chaplain (CH) were interviewed. TRC explained they don't typically program activities on the TCU as, from past experience, had not ever seen enough attendance to justify it. As a result, upon admission they meet with TCU residents' and explain

they are welcome to attend the activities on the other floors for the LTC residents. TRC stated if someone expressed wanting to be involved, then they'd likely be given an in-room calendar. CH explained they round

on the unit and do a scheduled program every other week, however, both CH and TRC verified they don't round on the units daily to invite residents on the TCU to activities. TRC stated any in-room activities would be offered on the initial evaluation adding if offered and declined, then such would also be indicated on the evaluation. When questioned on what, if any, re-evaluation process existed as people on the TCU are likely to have evolving health needs (i.e., get better, more energy), TRC explained the re-admission was not an automatic and they wouldn't typically re-visit it until the MDS cycle (i.e., quarterly) came due.

A facility' activities programming policy was requested, however, none was received.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 34 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