The Waterview Pines LLC

Based on interview and document review the facility failed to report an allegation of neglect of care related to a fall from a mechanical lift to the state agency (SA) for 1 of 3 residents reviewed for use of mechanical lifts.R1's admission Record indicated she admitted to the facility 6/1/23. R1's diagnosis included dementia with behavioral disturbance, back pain, other chronic pain, and spinal stenosis. R1's care plan dated 6/30/25, identified an alteration in cognition and an alteration in mobility. The care plan directed staff to transfer R1 via celling lift using a toileting sling when using the toilet and a full body split leg sling for all other transfers. R1's Incident Review and Analysis dated 8/1/25, indicated Staff was transferring R1 from the bathroom to the bed using a toileting sling and R1 fell out onto the floor and hit her head. During interview with the administrator and DON on 8/6/25 at 4:46 p.m., the administrator stated R1 was in a toileting sling and she fell through because she placed her arms inside the sling. The administrator stated the incident had not…

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 thoroughly investigate a fall from a lift resulting in significant injury for 1 of 3 residents (R1) reviewed for neglect of care.R1's admission Record indicated she admitted to the facility 6/1/23. R1's diagnosis included dementia with behavioral disturbance, back pain, other chronic pain, and spinal stenosis. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated she displayed no behaviors. The care plan indicted R1 was dependent on staff for transfers and was always incontinent of bowel and bladder.R1's Lift/Mobility Status Form dated 10/7/24, indicated she was unable to bear weight, was unable to follow simple instructions and was not cooperative with transfers. The form indicated use of a ceiling lift with assistance from one staff.R1's care plan dated 6/30/25, identified an alteration in cognition and an alteration in mobility. The care plan directed staff to transfer R1 via celling lift using a…

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 voiced concerns about the provision of care were acted upon timely and resolved to help potentially prevent occurrences for 3 of 3 residents (R1, R4, R6) reviewed who had voiced concerns about care from a staff member. Findings include: A facility-reported Vulnerable Adult Maltreatment Report (i.e,, FRI) dated, 7/16/25, identified R1 reported being handled roughly by a nursing assistant (NA) the night prior. The report identified NA-A as the alleged perpetrator and outlined they had been terminated from the care center. The report continued and identified another resident (R6) had reported concerns about how NA-A had transferred them and, again, that NA-A was rough with cares.R1's admission Minimum Data Set (MDS), dated [DATE], identified R1 had moderate cognitive impairment but demonstrated no delusional thinking. On 7/24/25 at 11:27 a.m., R1 was interviewed and recalled the incident from the week prior. R1 expressed it involved a male staff…

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 was a sufficient number of staff to ensure all resident cares were completed timely for 9 of 9 anonymous reporters (AR-8, AR-1, AR-2, AR-3, AR-3, AR-4, AR-5, AR-6, and AR-7) interviewed. Also for family members, (FM)-L with concerns of resident (R32) being left soiled for extended periods of time, and nail care not being provided and environment being left soiled with stool, FM-K for long call light times, and FM-C for having to provide care themselves to ensure bedtime cares would be completed. In addition, residents R29 and R7 for long call light wait times, resulting in urinary incontinence for R7, R32 who was not assisted with morning cares until 2:30 in the afternoon, R4 for lack of nail care, R8 who was receiving end of life cares, but not repositioned and provided comfort cares timely, and R1 who did not receive pain medications timely due to inadequate staffing. In addition six residents (R1, R5, R21, R22, R31, 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 observation, interview and document review, the facility failed to ensure orders for respiratory care were implemented for 1 of 1 (R23) resident reviewed for respiratory care. Findings include: On 11/17/24 at 5:29 p.m., R23 was in her room lying in bed wearing oxygen per nasal cannula at 2 liters per minute. R23's oxygen was humidified and the bottle was dated 10/16/24. R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 had diagnoses which included centrilobular emphysema (a form of chronic lung disease), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), pulmonary fibrosis (a condition in which the lungs become scarred over time. Symptoms include shortness of breath, a dry cough), atherosclerosis of aorta (a condition where plaque builds up in the walls of the aorta), morbid obesity with alveolar hypoventilation (insufficient ventilation), and chronic respiratory failure with hypoxia (an absence of enough oxygen in 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 to ensure timely repositioning and coordination of care for a hospice patient with a change in condition for 1 of 5 (R8) residents; to ensure provider orders for weight monitoring were followed for 1 of 5 (R26) residents; to ensure dressing changes were completed as ordered for 1 of 5 (R40) residents; to ensure placement of ankle-foot orthosis (AFO) for 1 of 5 (R32) residents; and to ensure timely delivery of medications for 1 of 5 (R1) residents reviewed for quality of care. Findings include: R8: R8's significant change in condition Minimum Data Set (MDS) dated [DATE], identified moderately intact cognition and diagnoses of dementia and congestive heart failure. R8 was dependent on staff for eating, bed mobility and toileting. R8's provider orders dated 9/30/24, identified hospice care through Essentia East Range Hospice with orders to call hospice first for changes in condition, need for additional services, medications, supplies,…

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 residents were supervised by nursing staff or trained feeding staff during dining for 1 of 1 (R20) resident reviewed for dining. Findings include: R20's annual Minimum Data Set (MDS) dated [DATE], identified R20's diagnoses included, dementia, multiple sclerosis (a disease in which the immune system eats away the protective covering of nerves), depression, and dysphagia (difficulty swallowing). R20's MDS identified R20 was severely cognitively impaired and required partial to moderate assistance with eating. On 11/18/24 at 6:24 p.m., one resident (R20) remained in the dining room with one dietary staff clearing tables. R20 remained at her table eating and drinking. -at 6:35 p.m., R20 remained alone in the dining room drinking beverages. -at 6:40 p.m., the dietary manager asked R20 if she wanted a ride to her room, shortly after that a nursing assistant entered the dining room and said she would take R20 to her room. On 11/19/24…

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 dispose of an expired bottle of half and half that was still available for residents to use. This had the ability to effect every resident who used half and half during meals. Findings included: On 11/19/24 at 1:24 p.m., an opened bottle of [NAME] half and half dairy product was noted in the refrigerator of the dinning hall dinette room. Hand written on the bottle was an open date of 11/8/24. The manufacture's expiration date was 11/14/24. During an interview on 11/19/24 at 1:30 p.m., culinary aide (CA)-A looked at the bottle and confirmed 11/8/24, was the dated the bottle was first opened. CA-A also acknowledged 11/14/24, was the manufacturer's expiration date on the bottle of half and half. CA-A stated dairy products like half and half are only good for 5 days after they are opened so this bottle of half and half should have been thrown away on 11/13/24, but for sure on 11/14/24, when the manufacturer says the dairy product is expired.…

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, observation and document reivew, the facility failed to ensure care was provided to preserve dignity for 1 of 3 residents (R52) that were reviewed for dignity. Findings include: R52's quarterly Minimum Data Set (MDS) dated [DATE], indicated R52 was cognitively intact with diagnoses of diabetes, depression, hemiplegia, and hemiparesis. Section GG -Functional Abilities and Goals indicated R52 required moderate assistance for personal hygiene and maximal assistance for shower/baths. R52's care plan last reviewed 10/8/24, included: -Focus area altered cognition related to anxiety - Resident will have all needs met by staff. Resident has a dx of anxiety and will not often utilize the call light or verbalize feelings or needs in fear of being a burden to staff. -Focus area altered elimination interventions identified resident is very shy and does not like to ask for help, she has a history of being very incontinent r/t not asking for assistance. -Focus area alterations in mood and behavior…

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 resident preference of being dressed and eating breakfast in the dining room was honored for 1 of 1 resident (R32) reviewed for resident rights. Findings include: R32's quarterly Minimum Data Set (MDS) dated [DATE], Section C - Cognitive Patterns, did not include a completed Brief Interview for Mental status. R32's quarterly MDS dated [DATE], indicated R32 had significant cognitive impairment. R32's diagnoses included neurological disorders, heart failure and non-Alzheimer's dementia with depression and anxiety. Section GG identified R32 required maximal assistance to total dependence for ADL's and was dependent for transfers. R32's careplan last reviewed 8/14/24, identified R32 preferred to dine in the main dining room and instructed staff to encourage resident to attend meals in the dining room where he could visit with others. Further, R32's care plan identified R32 required assistance with ADLS and preferred to get ready by…

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 equipment was not broken for 1 of 1 resident (R25) reviewed for environment. Findings include: On 11/17/24 at 2:03 p.m., R25 stated her toilet was broken and she was concerned about it. When facing the toilet the right side of the bowel was cracked near where the seat attached. On 11/19/24 at 1:06 p.m., licensed practical nurse (LPN)-A stated nursing assistants doesn't usually fill out a Tels slip, if something is broken they tell the nurse or call maintenance. On 11/19/24 at 1:08 p.m., LPN-B stated if staff see broken equipment they fill out a maintenance slip and it goes right into the computer to be fixed. LPN-B stated she was not aware of any residents complaining about a broken toilet. On 11/19/24 at 1:24 p.m., the regional director of maintenance (RDM)-A looked at the toilet and verified it was cracked. RDM-A stated the whole bowl needs to be replaced. RDM-A verified a request slip had not been filled out and stated he would have expected housekeeping to notice the cracked toilet and report it.…

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 complete all sections on the Minimum Data Set (MDS) for 2 of 18 residents (R23, R14) reviewed for resident assessment. Findings include: The Centers for Medicare and Medicaid (CMS) Long-Term Resident Facility Assessment Instrument (RAI) 3.0 User's Manual dated 10/2024, identified The purpose of this manual is to offer clear guidance about how to use the Resident Assessment Instrument (RAI) correctly and effectively to help provide appropriate care. Providing care to residents with post-hospital and long-term care needs is complex and challenging work. Clinical competence, observational, interviewing and critical thinking skills, and assessment expertise from all disciplines are required to develop individualized care plans. The RAI helps nursing home staff gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan. It also assists staff with evaluating goal achievement and revising care…

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 activities of daily living (ADL) were addressed for 2 of 4 residents (R4, R32) reviewed for ADLs. Findings include: R4: R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4's diagnoses included traumatic brain dysfunction, diabetes mellitus, hemiplegia/hemiparesis (a symptom that causes partial or total paralysis on one side of the body/muscle weakness or partial paralysis on one side of the body), and traumatic brain injury (TBI). R4's quarterly MDS identified R4 was severely cognitively impaired, sometimes understood and sometimes understands, had unclear speech, and was dependent on staff for ADLs. R4's care plan dated 8/21/19, identified R4 had a self care deficit with dressing, grooming, and bathing related to weakness and TBI. Interventions included nursing assistant to perform nail care for hands and feet on bath day. Weekly skin care assessments dated 11/11/24, 10/28/24, and 10/14/24, documented fingernails…

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 educate and document the education and refusals for pressure ulcer relief for 1 of 3 (R35) residents. In addition, the facility failed to ensure weekly skin inspections were performed as ordered and timely notification of the registered dietician (RD) of a resident's new and worsening wounds for 1 of 3 (R39) residents reviewed for pressure ulcers. Finding include: R35's significant change Minimum Data Set (MDS) dated [DATE], identified R35 had diagnoses which included hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction affecting left non-dominant side, dementia with behavioral disturbance, diabetes mellitus, depression, and morbid obesity due to excess calorie intake. R35's MDS identified he was severely cognitively impaired and required substantial/maximal assistance to dependent for activities of daily living. R35's care plan identified R35 had stage II 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 document review the facility failed to ensure a palm protector was used for 1 of 1 (R4) residents reviewed for range of motion. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4's diagnoses included traumatic brain dysfunction, hemiplegia/hemiparesis (a symptom that causes partial or total paralysis on one side of the body/muscle weakness or partial paralysis on one side of the body), and traumatic brain injury (TBI). R4's quarterly MDS identified R4 was severely cognitively impaired, sometimes understood and sometimes understands, had unclear speech, and was dependent on staff for activities of daily living (ADLs). R4's care plan dated 6/28/22, identified R4 had a self care deficit with dressing, grooming, and bathing related to weakness and TBI. Interventions included encouraging resident to wear foam built-up palm protector under left 4th and 5th digit to reduce contraction. Palm protector was to be on overnight and removed in the morning.…

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 for the use of PRN (as needed) lorazepam, a psychotropic medication (mood altering medication) was time limited to 14 days of use with a documented associated diagnosis for 1 of 5 residents (R28) reviewed for PRN psychotropic medication use. Findings include: R28's significant change Minimum Data Set (MDS) dated [DATE], indicated R28 had severe cognitive impairment. MDS Section I - Active diagnoses listed dementia, hyperlipidemia, arthritis, low back pain, ataxia, and adult failure to thrive. There were no diagnoses selected in Section I, Psychiatric/Mood Disorder Diagnosis. R28's careplan last reviewed 10/30/24, included psychotropic drug ADR [adverse drug reaction] monitoring, identified target behaviors and provided interventions for alterations in cognition, communication, and mood. R28's Order Summary Report dated 11/5/24, signed by provider on 11/8/24, included the following orders: -Lorazepam oral tablet 0.5 mg, give 1 tablet…

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 security of medical records for 1 of 1 (R8) resident reviewed for coordination of hospice care. Findings include: R8's significant change in condition Minimum Data Set (MDS) dated [DATE], identified moderately intact cognition and diagnoses of dementia and congestive heart failure. R8 was dependent on staff for eating, bed mobility and toileting. R8's provider orders dated 9/30/24, identified hospice care through Essentia East Range Hospice with orders to call hospice first for changes in condition, need for additional services, medications, supplies, questions, concerns, and notification of death. R8's care plan dated 3/14/23, identified hospice care related to end-stage disease process with interventions to maintain communication with hospice and keep them informed of resident's condition, or changes in condition, as needed. The Essentia Hospice care plan was not part of R8's electronic health record (EHR). On 11/19/24 at 2:48 p.m.,…

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 an elopement incident was reported to the State Agency (SA) not later than 24 hours for 1 of 3 residents (R1) reviewed for elopement. Findings include: A facility reported incident (FRI) submitted to the SA on 3/11/24 at 4:35 p.m. indicated R1 was found outside in her wheelchair, around 11:00 a.m. on 3/10/24. After further investigation, it was discovered the Code Alert Wander Management System sensor (a system that alerts staff when residents nears or exits an area of the building) had gone off for some time and when staff checked the door, they didn't see anyone and cleared the alarm. Upon staff clearing the alarm, R1 was found on the sidewalk next to the building. When bringing R1 back into the building, the alarm went off again. R1's significant change Minimum Data Set (MDS) dated [DATE] indicated R1 had delusions, severe cognitive impairment, and wandering that placed R1 at significant risk of getting to a potentially dangerous place.…

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 a registered nurse (RN) was scheduled for a minimum of eight consecutive hours a day. This had the potential to affect all 54 residents who resided at the facility. Findings include: The last two quarters of facility PBJ Staffing Data Reports, dated 1/1/23 through 3/31/23 and 4/1/23 through 6/30/23, identified the facility failed to have RN coverage for the dates of 3/11/23, 3/26/23, 5/21/23, 6/3/23, 6/4/23, and 6/24/23. The undated, facility payroll reports confirmed the facility did not have RN coverage for the specific dates listed on the PBJ Staffing Data Reports. During an interview on 10/3/23 at 5:45 p.m., administrator stated he knew why the specific payroll dates were requested as he was aware of no RN coverage on those dates. During an interview on 10/4/23 at 3:28 p.m., scheduling coordinator identified they are a union building and they must go through a seniority process. They have one RN in their float pool and if they aren't available, they attempt to use two different staffing agencies. It is often…

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 provide pneumococcal conjugate vaccine 20 variant (PVC20) education as directed by the Centers for Disease Control (CDC) for 4 of 5 residents (R32, R34, R40, R57) reviewed for immunizations. Findings include: R32's undated, facesheet identified R32 admitted to the facility on [DATE], and was [AGE] years old. R32's undated, Minnesota Immunization Report, identified R32 received the pneumococcal polysaccharide (PPSV23) on 4/25/91 and 10/17/97. R32 received the pneumococcal conjugate vaccine (PCV-13) on 6/13/17 and 6/16/17. R32's electronic health record (EHR) did not include evidence R32 or R32's representative received education regarding pneumococcal vaccine booster and there was no indication R32 was offered the pneumococcal vaccine per CDC guidance. R34's undated, facesheet identified R34 admitted to the facility on [DATE], and was [AGE] years old. R34's undated, Minnesota Immunization Report, failed to identify a history of pneumococcal…

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 provide the required liability and appeal rights notice two days or more prior to discharge from Medicare A services for 1 of 3 residents (R260) reviewed for beneficiary protection notification. Findings include: R260's last day of covered Medicare Part A Skilled Services was 6/20/23, as identified on the Notice of Medicare Non-Coverage (form CMS-10123). Form CMS-10123 was signed by R260 on 6/19/23. During an interview on 10/03/23 at 4:48 p.m., social services consultant stated she was unsure why form CMS-10123 wasn't done timely and should have been completed on 6/18/23. A progress note from 6/16/23, identified a last Medicare part A coverage date of 6/20/23, so the facility had time to issue form CMS-10123 prior to 6/19/23. The facility ABN/NOMNC Policy and Procedure dated 2/20/23, identified the business office manager as the primary person responsible for completing the Notice of Medicare Non-Coverage and it must be completed within 48 hours of being notified of a last covered day for a Medicare/Managed Care primary…

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 provide sufficient bowel tracking and notification to nursing of bowel movements for 1 of 2 residents (R9) reviewed for constipation. Findings include: R9's admission Minimum Data Set (MDS), dated [DATE], identified R9 had intact cognition and a diagnosis of colitis. R9's physician orders dated 8/4/23, directed staff to give docusate sodium 100 milligrams (mg) every morning and at bedtime for constipation; and sennosides-docusate sodium 8.6-50 grams every morning and at bedtime for constipation. R9's care plan dated 8/21/23, failed to address bowel tracking or identify issues with R9's bowel movements or constipation. R9's nursing progress note dated 8/23/23, identified R9 was constipated and was given milk of magnesia. The medical record lacked further notes regarding constipation and further treatments after 8/23/23. R9's physician orders dated 9/1/23, identified bisacodyl rectal suppository 10 mg for constipation as needed 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 observation, interview and document review, the facility failed to ensure interventions were implemented to promote healing and prevent pressure ulcer deterioration for 1 of 4 residents (R47) reviewed for pressure ulcers. Findings include: R47's quarterly Minimum Data Set (MDS), dated [DATE], identified R47 was cognitively intact and had diagnoses of left-sided hemiplegia (loss of motor function on one side of the body) and hemiparesis (one-sided weakness), venous insufficiency, diabetes mellitus with foot ulcer, non-pressure chronic ulcer right heel and midfoot, and noncompliance with medical treatment. R47 needed extensive assistance with bed mobility, was at risk for developing pressure ulcers, and had stage two and three pressure ulcers. R47's pressure ulcer Care Area Assessment (CAA) dated 7/14/23, identified R47 had two stage three pressure ulcers and made note of the wound care provider documenting the wounds as pressure ulcers. MDS coding followed provider documentation. Care plan considerations…

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 act upon consultant pharmacist's recommendation for 1 of 5 residents (R47) reviewed for unnecessary medications. Findings include: R47's quarterly Minimum Data Set (MDS) dated [DATE], identified R47 was cognitively intact and had diagnoses of diabetes mellitus with foot ulcer and non-pressure, chronic ulcers of the right heel. R47's provider orders dated 5/18/23, identified saccharomyces boulardii (a pro-biotic supplement) one capsule daily to be given for gut health during antibiotic therapy, but did not include an order for an antibiotic. A Consultant Pharmacist Medication Regimen Review form dated 7/20/23, identified a concern with the medication saccharomyces boulardii to be given for gut health during antibiotic therapy. The pharmacist's recommendation was to consider stopping the medication or updating the directions as R47 was no longer taking oral antibiotics. During an interview on 10/4/23 at 3:00 p.m., the director of nursing (DON)…

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 accommodate resident needs by ensuring the call light was within reach for 3 of 3 residents (R1, R2, R3) reviewed for call light usage. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 had severely impaired cognition with a diagnosis of stroke. R1's care plan dated 7/12/23 indicated R1 was at risk for falls with an intervention of Keep call light within reach. On 9/20/23 at 12:37 p.m., R1 was observed sitting in a wheelchair. R1's call light was attached to the bed behind R1. R1 was able to answer questions with either yes/no or other one-word answers. R1 answered no when asked if he was able to reach the call light. R1 answered holler when asked what he would do if staff assistance was needed. R2's quarterly MDS dated [DATE] indicated R2 had intact cognition with a diagnosis of congestive heart disease. R2's care plan dated 7/19/23 indicated R2 was at risk for falls with interventions of Call, don't fall sign in room 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.