Village at St Edward NRSG Care

In the surveyor’s words

From the most serious findings on record at Village at St Edward NRSG Care, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF569Sep 15, 2022

  Based on record review and interview the facility failed to ensure residents and/or their representatives were notified in writing when their personal fund account (PNA) reached $200.00 less than the Medicaid resource limit (of $2000.00). This affected four residents (#9, #49, #53 and #67) of six resident records reviewed for PNA accounts. Findings include: Review of the Trust Fund Balance Report dated 09/30/22 revealed the following: Resident #9, who received Medicaid benefit had a PNA balance of $3,551.33. Resident #49, who received Medicaid benefit had a PNA balance of $2,412.49. Resident #53, who received Medicaid benefit had a PNA balance of $3,415.85. Resident #67, who received Medicaid benefit had a PNA balance of $3,206.76. […]

• No harm, potential for more than minimal, patternF623Sep 15, 2022

  Based on medical record review and interview the facility failed to provide written notifications to residents and residents' representatives before transfer to a hospital. This affected four residents (#20, #63, #65 and #274) of five residents reviewed for hospitalization . Findings include: 1. Review of Resident #20's medical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note, dated 08/13/22 at 10:15 A.M. revealed Resident #20 was unresponsive and her head and extremities were flaccid. The note indicated Resident #20's color was gray and her skin was diaphoretic (sweating profusely). Resident #20 was drooling and a blood pressure was unable to be obtained. After being assisted to bed, Resident #20 opened her eyes and was able to respond verbally. […]

• No harm, potential for more than minimal, patternF625Sep 15, 2022

  Based on medical record review and interview the facility failed to provide timely written notifications to residents or residents' representatives related to the bed hold policy when residents were transferred to a hospital. This affected four residents (#20, #63, #65 and #274) of five residents reviewed for hospitalization . Findings include: 1. Review of Resident #20's medical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note dated 08/13/22 at 10:15 A.M. revealed Resident #20 was unresponsive and her head and extremities were flaccid. The note indicated Resident #20's color was gray and her skin was diaphoretic (sweating profusely). Resident #20 was drooling and a blood pressure was unable to be obtained. […]

• No harm, potential for more than minimal, isolatedF558Mar 2, 2026

  Based on observations, interviews, and resident record reviews, the facility failed to ensure call lights were in reach. This affected two residents (#8 and #67) of three residents reviewed for call lights. The facility census was 79.Findings include: 1. Review of the medical record for Resident #8 revealed she was admitted to the facility on [DATE] with diagnoses that included respiratory syncytial virus, fall, dementia, and anxiety.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had severe cognitive impairment. […]

• No harm, potential for more than minimal, isolatedF641Mar 2, 2026

  Based on observations, resident record review, resident interview, and staff interviews, the facility failed to accurately assess and document a resident's hearing status on the minimum data set (MDS) assessment. This affected one resident (#1) of four residents reviewed for assessments. The facility census was 79.Findings include:Review of the medical record for Resident #1 revealed she was admitted to the facility on [DATE] with diagnoses that included pulmonary fibrosis, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and type two diabetes.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had no cognitive impairment. […]