Heritage Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to provide the required written notices before a transfer to the hospital for 1 of 1 resident (R7) reviewed for hospitalization.Findings include:R7's significant change in condition assessment (SCSA) minimum data set (MDS) dated [DATE], identified intact cognition and diagnoses of right-side affected hemiplegia and hemiparesis, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD).R7's progress notes dated 7/27/26, didn't include information regarding a bed-hold.During an interview on 7/30/26 at 1:25 p.m., registered nurse (RN)-E stated they would ask the resident or representative if they would want a bed-hold and then they let social services director (SS)-C know. RN-E stated the nurses didn't use a form; she thought SS-C went over the form. During an interview on 7/30/26 at 1:26 p.m., SS-C stated the charge nurse would ask family if they would like a bed-hold and then make a progress note regarding verbal bed-hold obtained,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure the minimum data sets (MDS) was completed accurately and timely for 1 of 3 residents (R25) reviewed for activities of daily living, and 1 of 4 residents (R69) reviewed for quality of care and 1 of 1 resident (R43) for oral/dental. In addition, the facility failed to ensure the integrity of MDS data submitted to the Centers for Medicare and Medicaid Services (CMS) for 4 of 4 residents (R31, R39, R40, R61) reviewed for MDS accuracy.Findings include: R25: Per the Centers for Medicare and Medicaid Services (CMS) and the resident assessment instructions (RAI) manual, a significant change in assessment (SCSA) must be completed less by the end of the 14th day following determination that a significant change has occurred or 14 days after the assessment reference date (ARD). R25's SCSA MDS with an ARD of 4/9/26, identified moderately impaired cognition and diagnoses of malignant neoplasm of lung, and secondary neoplasm of bone. The RN assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to include dialysis to a resident's comprehensive care plan, who received dialysis while in the facility. This affected 1 of 1 (R2) residents reviewed for comprehensive care plans.Findings include:R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 was cognitively intact. Diagnoses included anemia, hypertension, and end stage renal disease. Section O: Special Treatments, Procedures, and Programs indicated R2 received dialysis while at the facility.R2's Active Order Summary Report dated 7/30/26, indicated an order to monitor perma-catheter site for pain, swelling, or signs of infection. The order summary report lacked orders related to R2's dialysis.R2's care plan lacked a care plan related to R2's dialysis and interventions to treat the dialysis, until a care plan was initiated on 7/28/26. During an interview on 7/28/26 at 12:49 p.m., R2 stated dialysis was received through the dialysis center in Hibbing, Mn on Tuesday, Thursday, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure orders were followed as written for 1 of 1 resident (R28) reviewed for quality of care. Findings include:R28's quarterly Minimum Data Set (MDS) dated [DATE], identified R28 had diagnoses which included multiple sclerosis (a long-lasting disease of the brain and spinal cord), diabetes mellitus, persistent atrial fibrillation (a common irregular heart rhythm where the upper heart chamber beats fast and out of sync with the lower chambers), hypertension, hyperlipidemia, heart failure (a chronic condition where the heart muscle cannot pump blood and oxygen well enough to meet the body's needs). In addition, R28's MDS identified he was cognitively intact and was dependent on staff for assistance with activities of daily living.During an interview on 7/30/26 at 4:24 p.m., family member (FM)-N expressed concerns about therapies not being continued since the new physical therapy department started. FM-N stated they had talked with the facility about…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure safe ambulation interventions were followed for 2 of 2 residents (R14, R75) reviewed. In addition, the facility failed to ensure resident equipment concerns were addressed in a timely manner to help prevent accidents for 1 of 5 residents (R9) reviewed for accident and safety concerns. Findings include: R14: R14's significant change Minimum Data Set (MDS) dated [DATE], identified R14 was severely cognitively impaired. R14's diagnoses included acute on chronic congestive heart failure, acute on chronic respiratory failure with hypoxia, hypertension, atrial fibrillation, difficulties in walking, abnormalities of gait and mobility, and weakness. R14's care plan revised 2/4/26 indicated that R14 required supervision with touching assist of 1 staff for ambulating with front wheeled walker (FWW). R14's physical therapy (PT) treatment encounter notes dated 6/10/26, identified R14 was doing gait training with stand by assist (SBA) without…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the tube feeding bottle was dated and timed when opened for 1 of 1 resident (R3) reviewed for tube feeding cares. Findings include:R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had diagnoses which included hemiplegia/hemiparesis (complete or severe paralysis on one side of the body/mild to moderate weakness on one side of the body), dysphagia (difficulty or discomfort when swallowing foods, liquids, or even saliva), hyperlipidemia, aphasia (a brain disorder that affects how one speaks, reads, writes, and understanding what other people say), hypertension. In addition, R3's MDS identified she had unclear speech, was severely cognitively impaired, and was dependent on staff for activities of daily living. R3's MDS also identified R3 received tube feedings.R3's current physician's orders reviewed on 7/28/26, identified she had orders for nocturnal feedings Jevity 1.5 at 83 milliliters (ml) per hour from 7:00 p.m. to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide hygienic care of oxygen and nebulizer equipment for 1 of 1 resident (R7) reviewed for respiratory care.Findings include:R7's significant change in status assessment (SCSA) minimum data set (MDS) dated [DATE], identified intact cognition and hemiplegia/hemiparesis r/t subarachnoid hemorrhage right side affected, Parkinsons, CHF, a-fib, COPD, anxiety, GERD, DM, dysphagia, insomnia, bipolar, acute pain, anemiaR7's care plan dated 4/10/26 identified oxygen therapy related to acute respiratory failure and CHF. Interventions included oxygen therapy, providing medications as ordered, monitoring for signs and symptoms of respiratory distress and report, oxygen setting at two liters per minute (LPM) to keep oxygen saturations above 88%.R7's provider order dated 11/18/25 identified oxygen at 2 LPM to keep oxygen saturations above 88% every shift. An additional order on 4/2/26 identified oxygen at one to four liters for shortness of breath as needed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure staff consistently used personal protective equipment (PPE) in resident rooms where precautions were in place to help prevent the spread of bacteria and potential for illness for 2 of 4 residents (R1, R2) reviewed for infection control. This deficient practice had the potential to cause illness for residents, staff, and visitors. In addition, the facility failed to ensure hygienic laundry practices to help minimize potential for bacteria growth.Findings include: R1: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 was cognitively intact. R1's diagnoses included chronic kidney disease, heart failure, hypertension, diabetes mellitus, anxiety, depression, and sleep apnea. R1's care plan dated 7/28/26, identified R1 was on enhanced barrier precautions (EBP) related to a history of Extended Spectrum Beta Lactamase (ESBL) infection in their urine and directed staff to follow EBP. R1's orders included Enhanced Barrier…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure there were sufficient numbers of staff to ensure all resident cares including getting residents out of bed when requested for 1 of 2 resident (R36) reviewed for choices, monitoring for and treating constipation for 1 of 2 (R16) and monitoring residents receiving dialysis for 1 of 1 resident (R111) reviewed for dialysis care. This had the potential to affect all residents residing in the facility. Findings include:Staff and Resident Interviews/Observations:On 6/23/25 at 2:53 p.m., R110 stated she had taken herself to the bathroom (said she had already waited 40 minutes) and was fearful of soiling self. R110 was tearful during the interview and further stated she had put on her artificial leg on to complete the transfer (even though she had not been cleared by therapy to do so). On 6/24/24 at 8:30 a.m., family member (FM)-F stated therapy had told them at the beginning of May there were only two nursing assistants for the entire…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and document review, the facility failed to maintain controlled medication accounting for facility stock medication and for 1 of 1 resident (R262) reviewed for medication side effects. The facility failed to ensure residents were free from medication errors for 1 of 1 resident (R262) who didn't receive their medication as ordered. In addition, the facility failed to remove expired facility stock medication which had to potential to affect any resident needing facility stock medication. Findings include: R262's admission Record dated 6/26/25, identified an admission date of 6/17/25 and a diagnosis of irritable bowel syndrome (IBS-D, a condition characterized by stomach pain, cramping and diarrhea).R262 had a provider order dated 6/17/25, for the medication eluxadoline (trade name Viberzi, a schedule IV-controlled substance used to treat IBS-D) oral tablet 75 milligrams (mg) two time per day. Review of R262's medication administration record (MAR) for June 2025, identified the number 9 appeared on 6/19 and 6/25 for the 7 p.m. dose, and on 6/23 for the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and document review the facility failed to ensure food was stored in accordance with professional standards for food service safety by failing to maintain safe food storage temperatures. This practice had the potential to affect all residents consuming food at the facility. OR Based on observation, interview, and record review, the facility failed to ensure beverages including milk were maintained and served at a safe temperature of less than 41 degrees Fahrenheit (F). In addition, the facility failed to ensure dishwasher temperatures were maintained for proper sanitization of dishes. These deficient practices had the potential to impact all residents residing at the facility Findings include: The facility form Weekly Temp Logs included at the bottom of the form: Temperature danger zone is 41 to 140 F. All food has to be held above or below this until meal service is complete. The breakfast section of the form did not include a section to record beverage temperatures. The lunch and dinner sections had a place to record dessert and milk temperatures.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure resident call lights were within reach from the bathroom floor in resident bathrooms for 4 of 4 residents (R36, R47, R111, R6) reviewed for call light accessibility.Findings include:During an observation on 6/23/25 at 2:33 p.m., the bathroom call light cord in R6's room was approximately three feet from the bathroom floor. During an observation on 6/23/25 at 5:31 p.m., the bathroom call light cord in R111's room was approximately three feet from the bathroom floor. During an observation on 6/23/25 at 6:18 p.m., the bathroom call light cord in R36's room was approximately three feet from the bathroom floor. During an observation on 6/24/25 at 9:14 a.m., the bathroom call light cord in R47's room was approximately three feet from the bathroom floor.On 6/24/25 at 12:08 p.m., maintenance director (M)-A went to each bathroom (405, 407, 410, 413) and verified the call lights were too short, M-A stated the call light cord should be reachable from the floor in case of fall in the bathroom. On 626/25 at 12:48 p.m., the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to get 1 of 2 residents (R36) out of bed when requested.Findings include:R36's quarterly Minimum Data Set (MDS) dated [DATE], identified R36 had diagnoses which included quadriplegia, fracture of surgical neck of left humerus with routine healing, anxiety, and depression. R36's MDS identified R36 was moderately cognitively intact, had no rejections of care, and was dependent on staff for bed to wheelchair transfers. R36's care plan dated 5/21/25, identified R36 had the potential for calling 911 if her call light was not answered fast enough or if she dropped something on the floor. Interventions included to try to answer the call light as soon as possible if not able to answer call light immediately to let R36 know when would be back (to give a length of time). In addition, R36's care plan dated 2/1/25, identified R36 had an activity of daily living (adl) self-care performance and required a mechanical lift with substantial maximal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed ensure residents were comprehensively assessed for self-administration of medications for 1 of 2 residents (R20) reviewed for self-administration of medication.Findings include:R20's significant change Minimum Data Set (MDS) dated [DATE], identified R20 had intact cognition with diagnoses that included heart disease, hypertension, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following nontraumatic subarachnoid hemorrhage (bleeding in the space between the brain and the protective layers covering the brain), Parkinson's disease, chronic atrial fibrillation, type 2 diabetes, congestive heart failure, chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs), anxiety, osteoarthritis, and dysphagia (difficulty swallowing).R20's provider orders reviewed on 6/25/25, included the following orders:-Advair Diskus inhalation aerosol powder breath activated 250-20 micrograms per…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure bathing preferences were honored for 1 of 1 resident (R10) reviewed for choices.Findings include:R10's significant change Minimum Data Set (MDS) dated [DATE], indicated R10 was cognitively intact with the diagnoses of congestive heart failure, diabetes and end stage renal disease. Section GG. indicated R10 required partial/moderate assistance with shower/bathing. R10's Care Plan Report last revised 5/7/25, identified R10 required partial/moderate assistance of one with bathing/showering. R10's care plan lacked identification of R10's preferences for personal hygiene and bathing.During an interview on 6/23/25 at 4:41 p.m., R10 stated they would like to have a shower two times a week. They didn't feel very clean by mid-week and felt like they were smelling a little. They really wished it could be two times a week, but nobody would do it. During an observation on 6/25/25 at 9:03 a.m., R10 was at the nurse station asking when they would…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the us of as-needed (PRN) psychotropic medication was limited to 14 days or extended to a certain date with supporting rationale provided by the medical provider for 1 of 5 residents (R20) reviewed for unnecessary medication use.Findings include:R20's significant change Minimum Data Set (MDS) dated [DATE], identified R20 had intact cognition with diagnoses that included heart disease, hypertension, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following nontraumatic subarachnoid hemorrhage (bleeding in the space between the brain and the protective layers covering the brain), Parkinson's disease, chronic atrial fibrillation, type 2 diabetes, congestive heart failure, chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs), anxiety, osteoarthritis, and dysphagia (difficulty swallowing).R20's provider order sheet reviewed on 6/25/25, identified order for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the baseline care plan did not cover the required elements for 1 of 2 residents (R110) reviewed for care plans.Findings include:R110's admission Minimum Data Set (MDS) dated [DATE], was in progress. R110 was admitted [DATE]. R110's provider orders dated 6/26/25, identified R110 had diagnoses which included acquired absence of right leg below knee, diabetes mellitus, lymphedema (swelling, most often in an arm or leg, caused by a lymphatic system blockage), and reduced mobility. R110's orders included the following:-Consistency CHO (carbohydrate) diet Regular texture, Thin consistency, limit of potassium to 2000 mg (milligram) dated 6/11/25-Apply Sequential Compression Device to left leg QD (every day) for 1 hour one time a day related to LYMPHEDEMA dated 6/12/25-Observe closely for side effects of Diuretic medication including decreased PO (oral) intake, acute confusion, agitation, delusions, aggression, lethargy, decreased sweating, tachycardia, hypotension, orthostasis,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure to develop a comprehensive care plan for 2 of 6 residents (R13, R33) reviewed for care planning. Findings include:R13:R13's admission Minimum Data Set (MDS) dated [DATE], indicated R13 was cognitively intact with the medical condition of fractures and other multiple traumas with the diagnoses of hip fracture and lymphedema. MDS Section N. indicated R13 received opioid pain medication and a diuretic. Section GG. indicated R13 was dependent for showering, toileting, transfers, and required maximal assistance for dressing. R13's care plan date last revised 6/2/25, included the following:ADL self-care performance focus identified R13 required assistance of one with for dressing, oral care, and one to two staff for bed mobility. Personal hygiene and toilet use read I require (specify assistance) by (x) staff for both areas. R13's care plan did not identify nor include focus areas and interventions for hip fracture/weight bearing status,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to revise the care plans to reflect current care needs for 2 of 6 residents (R37, R52) reviewed for care planning. Findings include:R37:R37's significant change Minimum Data Set (MDS) dated [DATE], identified intact cognition and hospice care. Diagnoses for R37 included hemiplegia and hemiparesis following a cerebral hemorrhage affecting the right side, diabetes mellitus, pneumonia, chronic kidney disease stage three, and chronic gout.R37's care plan didn't indicate a hospice status or contain coordination of care with St. Croix Hospice. During an interview on 6/26/25 at 8:47 a.m., the HUC stated she didn't keep hospice paperwork for St. Croix, any documents they had should be in the hard chart. During an interview on 6/26/25 at 10:20 a.m., the DON would expect there to be a hospice care plan for R37.R52:R52's quarterly MDS dated [DATE], identified limited range of motion (ROM) in both lower extremities. Was dependent on assist of two for toilet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure oxygen tubing and supplies were properly managed for 1 of 1 resident (R211) who was reviewed for oxygen use. Findings include: R 211's admit Minimum Data Set (MDS) dated [DATE], indicated R211 was mildly cognitively impaired with the diagnoses of emphysema and congestive heart failure.R211's Care Plan Report last revised 6/8/25, included R211's use of humidified oxygen of 1 to 4 liters related to diagnoses of congestive heart failure and emphysema.R211's Treatment and Medication Administration Record dated between 6/1/25 and 6/24/25, did not include documented oxygen tubing and/or bubbler changes. During an observation on 6/23/25 at 6:48 p.m., R211 was wearing oxygen tubing that was connected to an oxygen concentrator with bubbler (container with water to add moisture to received oxygen). Neither the oxygen tubing or bubbler were dated. R211 stated they were not sure when their oxygen tubing had last been changed.During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to follow dialysis orders for 1 of 1 resident (R111) reviewed for dialysis care. Findings include:R111's admission Minimum Data Set (MDS) dated [DATE], identified R111 had diagnoses which included dissection of thoracoabdominal aorta, anxiety, dependence on renal dialysis, and seizures. In addition, R111's MDS identified she was moderately cognitively intact, had no rejections of care and was receiving dialysis. R111's Order Summary report identified the following:Daily weights, update medical doctor for weight gain more than two pounds per day or five pounds per week. Dated 6/9/25.Ensure the dressing on the double lumen right internal jugular tunneled-site is intact. If comes loose re-secure, or replace dressing with a Tegaderm. Keep dressing clean and dry and lumens covered. Two times a day. Dated 6/9/25.R111's electronic treatment administration record (eTAR) identified the following:Daily weights missing on 6/13/25, 6/16/25, 6/18/25,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure medications were administered in accordance with physician orders for 2 of 4 residents (R37, R48) observed to receive medication. A total of three errors out of 34 opportunities were identified resulting in a facility error rate of 8%. Findings include: R37:R37's significant change Minimum Data Set (MDS) dated [DATE] identified intact cognition and hospice care. Diagnoses for R37 included hemiplegia and hemiparesis following a cerebral hemorrhage affecting the right side, diabetes mellitus (DM), pneumonia, chronic kidney disease stage three, and chronic gout. R37's medication administration record (MAR) for June 2025, identified an order on 4/2/25 for tart cherry ultra oral capsules 1200 milligrams (mg), give two capsules by mouth two times per day related to gout. During an observation and interview on 6/25/25 at 9:09 a.m., licensed practical nurse (LPN)-E was preparing R37's medications for administration and noted there was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain the hospice medical record for 1 of 1 resident (R37) reviewed for hospice care. Findings include:R37's significant change Minimum Data Set (MDS) dated [DATE] identified intact cognition and hospice care. Diagnoses for R37 included hemiplegia and hemiparesis following a cerebral hemorrhage affecting the right side, diabetes mellitus, pneumonia, chronic kidney disease stage three, and chronic gout.R37's care plan didn't indicate a hospice status or contain coordination of care with St. Croix Hospice. During an observation and interview on 6/26/25 at 8:38 a.m., R37's St. Croix Hospice binder was stored at the central nurse's station, it didn't contain any information. R37's hard chart was also stored at the nurse's station, and that chart didn't contain any hospice information. The hospice binder had sections for hospice contact information, admission documentation, charting forms for nursing assistants (NA)s, nurses, and care plans, all of which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to have infection control measures in place for a resident colonized with a multi-drug-resistant bacteria (MDRO, bacteria resistant to one or more classes of antimicrobial agents) for 1 of 1 resident (R41) reviewed for infection control. Findings include: R41's significant change Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses of obstructive and reflux uropathy, benign prostatic hyperplasia (BPH, non-malignant swelling of the prostate), and extended-spectrum beta-lactamase (ESBL, enzymes produced by certain types of bacteria that make them resistant to many common antibiotics) resistance, and urinary tract infection (UTI). The MDS also indicated R41 was occasionally incontinent of urine and had no catheter or toileting plan. R41's care plan dated 1/31/25, identified an activities of daily living (ADL) self-care performance deficit with interventions to assist with toilet use and hygiene when R41 requested. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide licensed nursing staff on a 24 hour basis for 8 days in the first quarter of fiscal year 2024. Findings include: The facility's certification and survey provider enhanced report (CASPER) identified 20 days between October 1st 2023 and December 31st 2023 when there was no licensed nursing staff in the facility. During interview on 5/17/24 at 10:52 a.m., director of nursing (DON) stated the facility was staffed well now and the gaps in the CASPER were a result of their payroll software not working correctly. The facility's payroll records confirmed the following days included gaps of 6 hours or more with no licensed nursing staff: -10/7/23, gap in coverage on night shift -10/15/23, gap in coverage on night shift -10/22/23, gap in coverage on night shift -11/5/23, gap in coverage on night shift -11/11/23, gap in coverage on night shift -11/18/23, gap in coverage on night shift -11/19/23, gap in coverage on night shift -12/17/23, gap in coverage on night shift Information on payroll software problem was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to perform an elopement risk assessment for 1 of 1 (R1) resident reviewed for elopement. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and included diagnoses of Alzheimer's disease, dementia without behavioral or psychotic disturbance, major depressive disorder, recurrent, severe with psychotic symptoms. R1's provider orders dated 4/12/24, identified an order for staff to check placement and function of a wanderguard located on R1's right ankle, using a hand-held device to check the battery function each shift and to ensure R1 had not removed the device. R1's care plan dated 8/21/23, identified a risk for wandering with interventions to have a wander guard in place to right ankle, move closer to nurse's station for supervision due to wandering, encourage to attend activities during highest wandering times. R1's medical record did not contain an assessment for elopement risk. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to implement occupational therapy (OT) orders for proper wheelchair positioning for 1 or 2 residents (R31) reviewed for positioning. Findings include: R31's quarterly minimum data set (MDS) dated [DATE], identified R31's diagnoses include Dementia, generalized muscle weakness, and hemiplegia (paralysis of one side of body). R31 was severely cognitively impaired, used a wheelchair, and required substantial/maximum assistance with dressing, grooming, and transferring. R31's care plan dated 6/23/22, identified to keep side supports in wheelchair when resident up in wheelchair to prevent leaning to the left. Therapy progress note dated 3/6/24, states evaluation for wheelchair positioning completed. Resident was provided with lateral side wedges to further prevent leaning to left side. Please keep side supports in wheelchair when resident up in chair. During observation's on 5/14/24 from 1:03 p.m. to 6:31 p.m., R31 was observed hunched forward…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain safe positioning for a resident with a feeding tube, while the tube feeding was running for 1 of 1 resident (R37) reviewed for tube feeding care. Findings include: R37's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and diagnoses of Parkinson's disease with dyskinesia (uncontrollable, uncoordinated movements), respiratory failure, pneumonitis due to inhalation of food and vomit, and dysphagia (a swallowing disorder). R37 was dependent on staff for oral hygiene, needed maximum assistance for bed mobility, and had a feeding tube. R37's provider orders dated 2/9/24, identified a nothing by mouth order, to provide medications via feeding tube only, and to keep head of bed (HOB) at 45 to 60 degrees for all feedings and flushes. Feeding times were 3 a.m., 9 a.m., 3 p.m., and 9 p.m. at 85 milliliters (mL) per hour. R37's care plan dated 4/27/23, identified R37 received nutrition through a feeding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure oxygen tubing was changed in a timely manner for 1 of 1 residents (R17) reviewed for respiratory care. Findings include: R17's significant change Minimum Data Set (MDS) dated [DATE], included diagnoses of heart failure, anxiety, type 2 diabetes, and a thyroid disorder. R17's physician orders dated 12/20/23, identified staff should change oxygen tubing weekly on Monday night shift. During observation on 5/14/24 at 12:22 p.m., oxygen tubing did not have a date. During observation on 5/17/24 at 9:12 a.m., oxygen tubing did not have a date. R17's treatment record indicated oxygen tubing was not changed in April or in May. During interview on 5/17/24 at 10:10 a.m., certified nursing assistant (CNA)-A stated nurses are responsible for changing oxygen tubing per orders. CNA-A confirmed there was no date on the oxygen tubing. During interview on 5/17/24 at 10:40 a.m., licensed practical nurse (LPN)-A stated nurses are responsible for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.