The Estates at St Louis Park LLC

In the surveyor’s words

From the most serious findings on record at The Estates at St Louis Park LLC, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jun 2, 2023

  Based on interview and document review the facility failed to ensure residents were free and protected from ongoing verbal, physical abuse, and deprivation of goods by nursing assistant (NA)-A for 11 of 13 residents (R1, R2, R3, R4, R5, R9, R10, R11, R12, R13, R14) who identified abuse by NA-A and were dependent on staff for daily living needs. The facility's failures resulted in an immediate jeopardy (IJ). The IJ began on 5/12/23 when NA-A returned to work after an allegation of sexual and physical abuse. This resulted in ongoing resident complaints of aggressive rough handling, deprivation of services, and ongoing resident expressions of fear, demoralization, humiliation, shame, and degradation. […]

• Immediate jeopardy, isolatedF689Oct 6, 2023

  Based on observation, interview, and document review the facility failed to comprehensively assess for appropriate level of supervision for safety in the community for 1 of 3 residents (R1) who had cognitive impairment and a history falls in the community unsupervised. The facility failures resulted in an immediate jeopardy (IJ) when R1 was assaulted and suffered facial injuries while out in the community. The immediate jeopardy began on [DATE], when R1 left the facility without staff awareness, was found by law enforcement 9.3 miles away with facial injuries and transferred to hospital. The immediate jeopardy was identified on [DATE], and the administrator was notified on [DATE], at 4:14 p.m. The immediate jeopardy was removed on [DATE], at 4:02 p.m. […]

• Immediate jeopardy, isolatedF689Apr 11, 2022

  Based on interview and document review, the facility failed to ensure adequate supervision to prevent and identify an elopement for 1 of 3 residents (R1) reviewed for elopement. This resulted in an immediate jeopardy (IJ) when R1 left the faciity on [DATE], and walked to a hospital 2.2 miles from the facility. The facility was unaware of R1's absence for 6.5 hours. The facility immediately implemented corrective action so the deficient practice was issued at past noncompliance. The IJ that began on 3/31/22, was corrected on 4/1/22, when the facility implemented interventions to prevent reoccurrence. The administrator and director of nursing (DON) were notified of the IJ on 4/11/22, at 4:50 p.m. […]

• Immediate jeopardy, isolatedF689Jun 2, 2021

  Based on observation, interview, and document review, the facility failed to ensure smoking interventions were implemented for 1 of 3 residents (R1) who was assessed to smoke unsafely. This failure resulted in an immediate jeopardy (IJ) situation when R1, who was on oxygen, lit a cigarette in her room and sustained [CONDITION(S)] to her face, shoulder, and chest. The facility immediately implemented corrective action and the deficiency is being cited as past non-compliance. The IJ began on 5/30/21, at approximately 10:40 p.m. when the facility fire alarm sounded, and smoke was observed coming from R1's room. R1, who was noted to have smoking products on her lap, had observable [CONDITION(S)] to her face, shoulder, and chest. […]

• Immediate jeopardy, isolatedF695Mar 19, 2021

  Based on observation, interview and document review, the facility failed to ensure nursing staff were trained in emergency procedures to establish an airway for a resident with a [CONDITION(S)] for 2 of 2 residents (R4 and R5) reviewed for emergency [CONDITION(S)] procedures. In addition, the facility failed to provide ongoing monitoring of respiratory and suctioning status; failed to have required emergency supplies readily available; failed to develop a policy addressing [CONDITION(S)] emergencies for 2 of 2 residents that received [CONDITION(S)] care (R4 and R5). This deficient practice resulted in an immediate jeopardy (IJ) situation for R4 who died as a result of respiratory distress, and for R5 who was at risk for serious illness or death. […]