Dove Healthcare - St Croix Falls

In the surveyor’s words

From the most serious findings on record at Dove Healthcare - St Croix Falls, in the surveyor’s own words.

• Immediate jeopardy, patternF689Oct 17, 2022

  Based on interview and record review, the facility failed to ensure a system was in place to check wander guard placement or functionality on residents with wander guards, and wander guard posting with photos was not updated with current list of wandering residents to help staff know who to supervise more closely to prevent elopement for 6 of 6 residents (R) who are at risk for wandering/elopement (R1, R2, R3, R4, R5, R6). Failure to ensure a system was in place to check wander guard placement and functionality and monitoring of residents at risk for wandering/elopement resulted in R1 eloping from the facility. This created a finding of immediate jeopardy that began on [DATE]. Surveyor notified the Nursing Home Administrator on [DATE] at 4:00 p.m. […]

• Immediate jeopardy, isolatedF678Jan 2, 2025

  Based on interview and record review, the facility failed to have a system in place to ensure the code status of residents (R), as indicated in their advance directives, was followed. This affected 1 of 1 resident reviewed (R1) whose Cardiopulmonary Resuscitation (CPR) wishes were not followed. R1's Critical Care Plan indicated R1 wanted CPR. On [DATE], R1 was found not breathing and without a pulse. Staff did not promptly begin CPR per resident's wishes. When CPR was initiated, it was not performed according to current standards resulting in ineffective procedure. The facility's failure to ensure R1 received basic life support, including CPR, in accordance with preferences on signed Critical Care Plan, created a finding of Immediate Jeopardy (IJ) beginning on [DATE]. […]

• Immediate jeopardy, isolatedF689Jun 5, 2023

  Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents with dining for 1 of 3 residents (R3) who required altered diets. R3 had three previous choking episodes and had orders for puree texture diet. R3 was served ground meat and creamed corn with visible corn kernels. Staff did not intervene and send food back to kitchen for replacement with correct texture food to ensure R3's safety and prevent choking. Failure to intervene when resident was served food in the inappropriate texture created a finding of Immediate Jeopardy (IJ), which started on [DATE]. Surveyor notified Nursing Home Administrator A (NHA) of the immediate jeopardy on [DATE] at 11:39 AM. […]

• Immediate jeopardy, isolatedF805Jun 5, 2023

  Based on observation, interview and record review, the facility did not ensure food was prepared in a form designed to meet individual needs for 1 of 10 residents (R) on mechanically altered diets. (R3) R3 had a choking episode in October 2022 and had orders for a mechanically altered diet. R3 was repeatedly served incorrect foods which resulted in two additional choking episodes that required intervention by nursing staff to clear R3's airway. On 05/30/23, observation showed R3 was served foods that did not meet standards for the current diet order of pureed. Failure to ensure foods were served to residents in the appropriate texture created a finding of Immediate Jeopardy (IJ), which began on 04/06/23. […]

• Actual harm, isolatedF686Feb 19, 2025

  Based on observation, interview and record review, the facility did not ensure 1 of 3 residents (R) reviewed for pressure injuries (PI) received care consistent with professional standards of practice to prevent the development of a new pressure injury and promote healing of existing PIs (R1). R1 was admitted to the facility without a PI and was assessed to be at risk for PI development. R1 developed one PI a deep tissue injury (DTI) on 01/22/25. The facility did not have preventive measures of heel boots in place prior to the development of the DTI. […]