Three Links Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure resident choices for bathing preferences were assessed and honored for 1 of 1 residents (R1) reviewed for choices. Findings Include: R1's admission Minimum Data Set (MDS), dated [DATE], indicated R1 had intact cognition with no hallucinations or delusions. The assessment indicated R1 needed moderate staff assistance with dressing, toileting hygiene, personal hygiene and footwear. On 7/28/25 at 6:33 p.m., R1 stated that she preferred to have a shower in the evening. R1 stated the facility had always given her showers during the day except for one time when they did not have time to complete it during the day and gave her a shower in the evening. R1 stated how much she enjoyed the shower in the evening and I have told everybody how much I liked the shower in the evening. R1's care plan, printed 7/29/25, identified the following: -Resident preferences will be considered when providing care with the following preferences: bedtime preference of 10…

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 Set (MDS) was accurately coded, with the potential for inaccurate federal reimbursement and resident care planning for 1 of 5 residents (R48) reviewed for MDS accuracy. Findings include:The Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2024, indicates clinical standards do not support reverse staging or back-staging as a way to document healing as it does not accurately characterize what is occurring physiologically as the ulcer heals, as the tissues lost will never be replaced with the same type of tissue (page M-7). The manual instructs that once a pressure ulcer is healed, it should be documented as a healed pressure ulcer at its highest numerical stage, as it would remain at an increased risk for future breakdown and require continued monitoring and preventative care (page M-8). The manual indicates that a previously closed pressure ulcer…

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 the dignity of 1 of 2 residents (R31) reviewed who were cognitively impaired and had facial hair. Findings include:R31's admission Minimum Data Set (MDS) assessment dated [DATE], identified admission to the facility on 7/10/25, with diagnoses of non-Alzheimer's dementia, arthritis, depression, and cataracts. R31 had moderate cognitive impairment, used a wheelchair for mobility, required substantial assistance from staff for hygiene to include combing hair, shaving, washing/drying face and hands, baths, showers, and oral hygiene.R31's care plan dated 7/10/25, identified activity of daily living (ADL) interventions for bed mobility, oral cares, toilet use, transfers, bathing and showering, dressing and eating. Bathing and showers required a mechanical lift with assist of two staff for transfers. The plan lacked interventions to address shaving or grooming facial hair. A care sheet for July 2025 lacked documentation R31 received any…

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 enhanced barrier precautions (EBP) were followed for 1 of 2 residents (R3) reviewed for infection control related to the management of a tube feeding.Findings include:R53's quarterly Minimum Data Set (MDS) dated [DATE], indicated R53 was cognitively intact, and had no behaviors or hallucinations. MDS also indicated R53 had difficulty swallowing and received enteral feeding via a tube.R53's Clinical Diagnosis Report dated 7/31/25, indicated dysphagia following cerebral infarction, pharyngeal dysphagia, diverticulum of esophagus, gastrostomy, anxiety and gastro esophageal reflux.R53's Clinical Orders Report indicated R53 had orders for enteral feeding, medications via tube feeding, and nothing per mouth. Orders Report also indicated special instructions for EBP.R53's care plan printed on 7/31/25, titled feeding tube, directed staff to use infection control precautions and related techniques following the manufacture recommendations…

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 comprehensively re-assess for safe self-administration of medication given via a nebulizer for 1 of 1 residents (R37) reviewed for self-adminstration of medications. Findings include: R37's quarterly Minimum Data Set (MDS) dated [DATE], indicated R37 had intact cognition and was diagnosed with respiratory failure and Chronic Obstructive Pulmonary Disease (COPD- incurable lung disease causing breathlessness, frequent coughing, and chest tightness). The MDS indicated that R37 was receiving hospice services. R37's Self Administration of Inhaled Medications assessment dated [DATE] and 5/14/24, indicated R37 was able to demonstrate correct administration of medication via a nebulizer after staff set-up. R37's Self Administration of Inhaled Medications assessment dated [DATE], indicated R37 was able to correctly demonstrate how to use a nebulizer but due to staff reports of R37 falling asleep while completing the medication administration, he…

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 identified preferences for bathing routines (i.e., twice weekly) were honored to promote quality of life and resident' choice for 1 of 2 residents (R7) reviewed for choices during the survey. Findings include: R7's quarterly Minimum Data Set (MDS), dated [DATE], identified R7 had intact cognition. On 5/20/24 at 2:09 p.m., R7 was interviewed, and she expressed frustration with her bathing routine adding, I was getting two baths a week but now they [staff] told me I'd only be getting one. R7 stated staff told her this a few weeks prior and she was not given a reason for the reduced bathing schedule, at least to her recall. R7 reiterated she wanted her second (in a week) bath re-scheduled adding, That would be nice. R7 stated she assumed they reduced it due to a lack of staff adding, They got so many people [other residents] here. R7's care plan, dated 4/10/24, identified R7 needed assistance with activities of daily living (ADLs) due to weakness…

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 interview and document review, the facility failed to ensure resident' trust account balances above the state-required supplemental security income (SSI) threshold (i.e., $3,000) were identified and acted upon to ensure ongoing coverage and reduce the risk of complication for 2 of 2 residents (R13, R42) reviewed who had balances exceeding the threshold. Findings include: A Minnesota Medical Assistance Treatment of Assets and Income, dated 9/2023, identified a person with medical assistance (i.e., Medicaid) living in a nursing home must contribute most of their income towards the cost of such care. The article outlined, The MA [medical assistance] asset limit is $3,000 for an individual and $6,000 for a couple, plus $200 for each dependent. A provided Trial Balance list, dated 5/22/24, identified all resident' trust accounts and their subsequent balances for the care center. This list identified R13 had an active balance recorded, [$]14,648.82, and R42 had an active balance recorded, [$]12,740.57. R13's Clinical Census, printed 5/23/24, identified R13 had a current payer…

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 a comprehensive care plan was developed to reflect assessed needs and interventions with pain relief for 1 of 2 residents (R7) reviewed for pain management. Findings include: R7's quarterly Minimum Data Set (MDS), dated [DATE], identified R7 had intact cognition and demonstrated no delusional behaviors. Further, the MDS outlined R7 consumed a schedule pain medication, received non-pharmacological interventions for pain, and occasionally complained of pain (including with affect on activities and sleep) during the review period. On 5/20/24 at 2:17 p.m., R7 was interviewed and expressed they had pain in their left leg from a fall weeks prior. R7 stated, It aches in this leg. R7 stated they were unsure if the physician was aware of it or not, and expressed the pain was worse with movement. R7 stated they were unsure if staff were aware of her pain or not adding, I don't know. R7's most recent Pain Data Collection - V9, dated 3/22/24, identified…

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 comprehensively assess for range of motion (ROM) after a significant change for 1 of 1 residents (R31) evaluated for limited mobility. Findings include: R31's significant change Minimum Data Set (MDS) dated [DATE], indicated R31 had severe cognitive impairment with no history of behaviors or rejection of cares. R31 had ROM impairment to one upper extremity, no ROM impairment to lower extremities, and was dependent on staff for all activities of daily living (ADLs). R31's diagnoses included unspecified dementia, traumatic brain injury and contracture of left hand. R31's care plan printed 5/22/2024, indicated R31 required total assist with ADL's. During an interview on 5/20/2024 at 6:03 p.m., family member (FM-A) stated they wanted R31 to participate in ROM/therapy exercises. FM-A stated she was informed by therapy R31 sleeps all the time and would not be appropriate for exercises. FM-A stated R31 is awake and participates in ball toss…

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 dental services were offered or provided in a timely manner to prevent complication (i.e., trouble eating, pain) for 1 of 1 resident (R39) after it was determined their dentures were loose and not fitting correctly. Findings include: R39's admission Minimum Data Set (MDS), dated [DATE], identified R39 admitted to the care center on 4/11/24 from the acute care hospital. The MDS recorded R39 as having intact cognition and demonstrating no delusional thinking. Further, a section labeled, Section L - Oral/Dental Status, identified R39 as having broken or loose fitting denture(s) and no natural teeth (i.e., edentulous). R39's Census listing, printed 5/22/24, identified R39's current payer source as, Private Pay. On 5/20/24 at 1:34 p.m., R39 was interviewed and expressed, I don't have teeth. R39 explained she had several dental implants but still had dentures, however, was not wearing them due to them being loose-fitting. R39 stated she thought, 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, interview, and document review, the facility failed to ensure proper infection control practices were utilized while completing personal hygiene and urinary catheter care for 1 of 1 residents (R25) reviewed for urinary tract infections (UTI). Findings include: R25's significant change Minimum Data Set (MDS) dated [DATE], indicated R25 had intact cognition and was diagnosed with heart failure, kidney disease, and respiratory failure. The MDS indicated R25 was dependent on staff for toileting hygiene, bed mobility, and transfers. R25's care plan dated 2/22/24, indicated R25 had a history of a UTI related to an obstruction of the urinary tract and also utilized a urinary catheter. The care plan indicated that R25 required assistance with catheter care every morning and night. The care plan indicated R25 required the assistance of two staff members with bathing and dressing. R25's order summary dated 2/22/24, indicated R25 had an indwelling urinary catheter in place and output was to be…

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 frozen food items were stored in a manner to reduce the risk of cross contamination and potential foodborne illness in 1 of 1 walk-in freezers using the main production kitchen. This had potential to affect all residents who could potentially consume the items. Findings include: On 8/14/23 at 1:42 p.m., an initial kitchen tour was completed with the director of culinary service (DCS) present. A single CrownTonka walk-in commercial freezer was in use, opened, and inspected. The outside of the freezer door had a white sign posted which read, Be very careful in freezer! Floor is very [underlined] slippery!! Walk like a penguin!! Inside, the unit had a cooling fan mounted to the top of the unit which had various black-colored, foam-wrapped piping entering the fan unit on the right side. The wrapped piping exited the back of the unit, ran along the back wall of the freezer to the opposite side, then entered the wall. However, the piping had visible ice built up in numerous places including along the unit.…

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 comprehensively assess, develop and implement interventions to address unplanned weight gain for 1 of 1 resident's (R13) who sustained an undesired weight gain of 41 pounds over the last 15 months. Findings include: The Centers for Disease Control and Prevention (CDC) About Adult BMI article dated 6/3/22, indicated a body mass index (BMI) for adults (over the age of 20 years) of 30.0 and above was obese. The article also indicated people who were obese were at an increased risk for many disease and health conditions including but not limited to: death, high blood pressure, diabetes, heart disease, stroke, osteoarthritis (a degenerative joint disease), mental illnesses (depression, anxiety) and a low quality of life. R13's significant change Minimum Data Set (MDS) dated [DATE], indicated R13 had intact cognition, was independent for eating, required limited assistance for transferring and extensive assistance for all other activities of daily living…

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.