The Emeralds at St Paul LLC

In the surveyor’s words

From the most serious findings on record at The Emeralds at St Paul LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 25, 2025

  Based on observation, interview, and document review, the facility failed to provide adequate supervision and identify a foreseeable hazard for 1 of 3 residents (R1) reviewed who required supervision. R1's was found unsupervised on two occasions; On 6/7/27 while outside in the staff smoking area and on 6/13/25 as a result of nonfunctional wanderguard and the facility not performing physician ordered 15-minute checks was found at a busy intersection. This resulted in an immediate jeopardy for R1 health and safety.The Immediate Jeopardy (IJ) began on 6/7/25, was corrected on 6/14/25 when the facility implemented interventions to prevent reocurrance. […]

• Immediate jeopardy, isolatedF686May 5, 2025

  Based on observation, interview, and document review, the facility failed to complete a comprehensive skin assessment identifying pressure ulcers, treatments, and monitoring, resulting in serious harm, for 1 of 3 residents (R1) reviewed for pressure ulcers. R1 returned from a hospital admission and the hospital discharge summary indicated upon admission to the hospital, R1 had pressure ulcers to his coccyx, left heel, right heel, lateral right foot. The treatment for all the wounds was to cleanse and change the dressing. […]

• Immediate jeopardy, isolatedF697May 5, 2025

  Based on observation, interview, and record review the facility did not ensure a residents pain was managed in accordance with professional standards of practice and hospice plan care, for 1 of 3 residents (R1) reviewed for pain. R1's medication regimen was ineffective; he would scream and moan in pain contacting EMS and his daughter for help. This resulted in immediate jeopardy (IJ) when the facility did not have a system in place to manage R1's pain causing R1 unnecessary physical and psychological harm. The immediate jeopardy began on 4/1/25 when R1's pain medication became ineffective and subsequently lacked follow-up of effectiveness, the patient called emergency services for pain medication, and called his daughter crying in pain, and was identified on 4/28/25. […]

• Immediate jeopardy, isolatedF849May 5, 2025

  Based on observation, interview and document review, the facility failed to establish a communication process between the facility and the hospice provider to ensure that the needs of a resident were addressed and met for 1 of 3 residents (R1) reviewed for hospice services. This resulted in an immediate jeopardy (IJ) when R1 did not receive the necessary care and services for the treatment of pressure ulcers and pain management. R1's pressure ulcer went untreated for approximately six weeks and R1's pain was not controlled, limiting staff's ability to perform activities of daily living for R1. In addition, the facility failed to have a designated member of the interdisciplinary team who was responsible to work with hospice to ensure residents receiving hospice services needs were met. […]

• Immediate jeopardy, isolatedF689Jul 30, 2024

  Based on observation, interview and document review, the facility failed to assess, monitor for side effects and drug interactions, implement interventions and follow facility policy to ensure the safety of 2 of 3 residents (R1, R6) who were reported to use crack cocaine all weekend on the facility smoking patio. This resulted in an immediate jeopardy (IJ) for R1 and R6 and had the potential to affect 20 other residents who were identified at risk for illicit drug use. The IJ began on 7/6/24 when R1 and R6 were seen smoking crack cocaine on the facility patio and were not assessed or monitored for potential life-threatening side effects and drug interactions. The director of nursing and administrator were notified of the IJ on 7/25/24 at 5:10 p.m. […]