Southview Acres Healthcare Center

the HUC was responsible for uploading a copy of the signed bed-hold and transfer form into the

recall filling out bed-hold or transfer form prior to sending R17 to the hospital. LPN-I stated, it should

staff to print a face sheet, medication list, and POLST to accompany the resident to the hospital.During interview with registered nurse (RN)-A on 3/12/26 at 11:26 a.m., RN-A stated expectation of nursing staff to immediately provide a copy of the bed-hold policy and notice of transfer to the patient or guardian prior to transfer to hospital. In addition, the resident face sheet, medication list and current POLST to all accompany resident to the hospital. RN-A stated expectation of facility staff to upload a signed copy of the notice of transfer to the resident's electronic medical record (EMR). RN-A verified both R10 and R17's EMR lacked documentation of a bed-hold/transfer notice, and a progress note to indicate it was done.During interview with director of nursing (DON) on 3/12/26 at 11:04 a.m., DON stated expectation of staff to provide copy of bed-hold policy and notice of transfer when residents were leaving the building for hospitalizations. DON stated a signed copy should be scanned into the EMR. As for notifying the Office of the State Long-Term Care Ombudsman of discharges and transfers, DON stated the director of social services (SS)-D is responsible for that task.During interview with SS-D on 3/12/26 at 11:17 a.m., SS-D stated she was responsible for sending discharge notifications to the State Ombudsman monthly.

However, SS-D stated she was unaware of needing to send notices of transfers and hospitalizations to the Office of the State Long-Term Care Ombudsman too., and stated, I did not know that I had to.Attempts to call/contact R10 and R17's guardian and primary emergency contacts and the Ombudsman were made but no answer or call back was obtained.Undated facility policy titled Transfer or Discharge Notice identified expectation of facility to provide transfer or discharge notice to resident where, An immediate transfer or discharge is required by the resident's urgent medical needs. In addition, The resident and/or representative will be notified in writing of the following information which included the facility bed-hold policy and, A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman.

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

During an interview on 3/12/26 at 8:01 a.m., licensed practical nurse (LPN)-E stated that R25 was receiving hospice care and had been since his admission to the facility.

During an interview on 3/12/26 at 9:20 a.m., the MDS Coordinator (MDSC)-A stated the GG section of the MDS was discussed daily at their morning team meeting and was also assessed by utilizing the resident's electronic medical record (EMR) to determine how well a resident functions and how much support they need with activities of daily living (ADLs).

The MDSC-A stated they attempt to coordinate baths for each resident to fall within the 3-day lookback period but that it can be challenging with the large size of their facility.

The MDSC-A confirmed R5's and R8's GG section of their most current MDS was dashed as not assessed.

The MDSC-A also stated it was their responsibility to indicated on the MDS if a resident was receiving hospice services which was determine based on a list the chaplain send out with all residents receiving hospice services listed.

The MDSC-A confirmed R25's most current MDS did not indicated R25 was receiving hospice services, and it should.

A facility policy titled Resident Assessments, dated 11/30/2021, indicated the resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews.

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

During the interview R13 rated his pain as 7. R13 said the pain comes and goes.During interview on 3/10/26 at 3:21 p.m., nurse manager/licensed practical nurse (LPN)-C stated R13 had problems with pain. LPN-C stated R13 scheduled an appointment to see a doctor due to severe foot pain.During interview on 3/11/26 at 10:44 a.m., LPN-C verified his pain management had not been care-planned.During interview on 3/11/26 at 10:49 a.m., the director of nursing (DON) stated R13 should have had a care plan for pain and she expected the staff would assess resident's pain and monitor for side effects and pain therapy effectiveness.A facility policy titled Comprehensive Person-Centered Care Plans dated 11/30/21, indicated the comprehensive, person-centered care plan will include measurable objectives and timeframes, and describe the services that are furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being.

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

interventions would be derived through analysis of the information gathered as part of the

furnished to attain or maintain the resident's highest practicable well-being.

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

During an interview on 3/11/26 at 1:03 p.m., clinical manager and licensed practical nurse (LPN)-C stated R123's interventions depended on who the aide was that was working, stating R123 would often refuse cares but a few aides were able to get her up and out of bed. LPN-C stated the aides who worked with the residents rotated to different units but work well together. LPN-C confirmed the care plan needed to be updated to remove wound care and confirmed there had been no updates to the potential for skin impairment care plan since R123 developed a pressure injury in January. LPN-C stated she believed the current interventions were effective because R123. had the one issue and hasn't had anymore.During a follow up interview on 3/12/26 at 11:02 a.m., clinical manager and LPN-C stated R123 should not be getting a silicone dressing on her coccyx as the wound resolved and there were no new orders after the wound healed for continued dressing, only barrier cream. LPN-C also confirmed R123 was not on a specific turning and repositioning schedule.

During an interview on 3/12/26 at 12:10 p.m., the director of nursing (DON) stated that even though R123 was on hospice care she would expect to see new care planned interventions for pressure injury prevention and skin protection after the development of a pressure injury, stating, we still don't want to see pressure injuries in hospice.A facility policy titled Prevention of Pressure Injuries, dated 3/6/25, instructed staff to reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team and to review the interventions and strategies for effectiveness on an ongoing basis.

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

During interview with director of nursing (DON) on 3/12/26 at 11:09 a.m., DON stated expectation of all residents, Should be seen annually at least and documented in the chart that it was done. DON verified R87 EMR failed to indicate any dental services were offered or provided.

Attempts at contacting R87's responsible party were made but no answer or call back was obtained.

The facility policy regarding dental services dated 2/8/22, indicated all dental services provided are recorded in the resident's medical record.

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

During an interview on 03/0926 at 12:24 p.m., the administrator stated the PBJ information was submitted through their corporate team, and he would look into how this was missed.

During a follow up interview on 12:10 p.m., the administrator stated he spoke with his corporate team, and it was discovered the wrong facility's information was uploaded in place of their facility's staffing information and it didn't stick in the system. A facility policy titled Payroll Based Journal, dated 3/2/25, indicated it was the policy of the facility to adhere to the mandatory submission of staffing information based on payroll data with a deadline of February 14th for fiscal quarter 1 submissions.

The policy further indicated, Section 6106 of the Affordable Care Act (ACA) requires facilities to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data.

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

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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

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

During interview with LPN-C on 3/10/26 at 8:43 a.m., LPN-C stated she was nursing manager of unit where R73 resided. LPN-C stated expectation of staff to wear [sic] PPE when entering the room to give meds for residents who were identified as being on Contact Precautions. LPN-C stated, hand hygiene is important to protect both the resident and staff.

During interview with infection control preventionist (IP) on 3/10/26 at 8:49 a.m., IP stated expectations that if a resident was identified as being on contact precautions, and if [staff] was administrating medications, then there would be no need to wear any PPE but should use hand hygiene before entering the room.

Facility policy titled Administering Medications, reviewed 12/13/2021 state, Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications.