The Gardens At Winsted LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and documentation, the facility failed to identify personal activity preferences, develop resident specific care plan, and coordinate activities of interest for 5 of 5 residents (R3, R22, R28. R31,and R36 ) reviewed for activities. Findings include: R3 R3's annual Minimum Data Set (MDS) assessment, dated 1/2/25, indicated R3 was cognitively intact and was readily able to communicate her thoughts, needs and wishes. R3's quarterly assessment of 4/4/25, indicated R3 had lower extremity deficit in mobility and was able to get around with the use of a wheelchair. R3's medical diagnoses included metabolic encephalopathy (brain dysfunction caused by systemic metabolic disturbances), anemia (a disease caused by low red blood cells that can cause shortness of breath and fatigue), hypertension (high blood pressure), diabetes mellitus (a group of disease that affect how the body uses blood sugar), arthritis (swelling or tenderness of one or more joints), multiple sclerosis (a chronic disease…

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 self-administration of medications assessment was completed, and orders obtained, for all medications kept at bedside for 1 of 1 residents (R9) observed with medications at their bedside. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated R9 was alert and oriented and able to communicate her needs. The MDS lacked any indication of behavioral concerns. R9 was able to complete activities of daily living (ADLs) independently, except for meeting her toileting and bathing needs. R9's medical diagnoses included anemia (low levels of healthy cells to carry oxygen), depression (a mood disorder with symptoms of sadness), chronic obstructive pulmonary disease with acute exacerbation (a persistent respiratory disease that may cause long-term, progressive lung damage), insomnia, nicotine dependence, chronic pain syndrome, gastroesophageal reflux disease (GERD), osteoporosis, unspecified fall, history of cerebral…

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 act and ensure voiced concerns in the resident council were addressed in a timely manner. This had potential to affect 6 of 6 residents (R8, R28, R33, R7. R3, and R11), identified to have attended the meetings in the past two months. Findings include: On 4/30/25 at 8:32 a.m., the resident council president (R7) gave permission for the survey team to review previous minutes of resident council meetings. These minutes were provided and identified the following concerns: October 14, 2024: No resident attendance roster included in the meeting minutes. Concerns identified related to Therapeutic Recreation: Identified goal to get more activities/crafts for residents. November 11, 2024: No resident attendance roster included in the meeting minutes. Concerns identified related to Therapeutic Recreation: Trying to get more games and exercises going. More crafting. Bingocize has stopped. Bingo is transitioning. December 9, 2024: No resident attendance roster included in the meeting minutes. Concerns identified related…

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 record review and interview the facility failed to follow up on grievances for 1 of 1 residents (R7) reviewed for grievances during the period 9/7/24 to 5/1/25. Findings include: On 4/30/25 at 3:14 p.m., during Resident Council, the question was asked: If the facility does not respond to concerns, does the Grievance Official provide a rationale for the response. R7 stated he was aware of the grievance process, and had filed multiple grievances, however, stated the last grievances, he did not received a response. A request was made for the grievance log from the past six months, as well as the resolutions of the grievances received. A log was received from 10/24/25 to 5/1/25. During this time, grievances were filed by R7 on 9/7/24, 11/18/24 (twice, for separate issues), 12/15/24, 12/15/24, 12/21/25, and 1/13/25. A resolution form was completed for the grievance of 9/7/24, with documentation completed on 10/14/24, which identified Grievance confirmed. The documentation indicated: investigation was ongoing and told resident [we] would continue to check in. Additionally, 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 the hospice plan of care had been integrated with the facility care plan for 1 of 1 resident (R2), identified to receive hospice services. Findings include: R2's 3/21/25, significant change Minimum Data Set (MDS) identified her cognition was severely impaired, and was dependent on staff for activities of daily living (ADL)s. R2 had diagnoses of anemia (low levels of red blood cells (which carry oxygen to the tissues) which causes weakness and fatigue), hypertension (high blood pressure), arthritis (inflammation of the joints), neuropathy (nerve pain which can lead to pain, weakness, or numbness), and urinary retention, . A review of R2's current care plan identified R2 was on hospice, however, lacked indication as to what services hospice provided during their visits to the facility. Although the facility care plan directed staff to refer to Hospice plan of care and visit schedule, the medical record lacked this information for staff reference. During interview on 5/1/25 at 8:54 a.m., hospice nurse…

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 appropriate monitoring of wanderguard function for 1 of 1 residents (R32) reviewed for elopement. Additionally, the facility failed to assure proper ongoing storage and use for e-cigarette (inhaled nicotine) device were implemented for 1 of 5 residents (R9) reviewed for smoking. In addition, the facility failed to provide supervision in the dining room during meal for 1 of 1 residents (R30) reviewed for safety while eating. Findings include: R32 R32's annual assessment of 12/13/24, indicated R32 had moderate cognitive impairment. R32's quarterly Minimum Data Set (MDS) dated [DATE], indicated R32 did not display episodes of inattention, disorganized thinking, or altered level of consciousness. The MDS also indicated R32 did not display physical or verbal symptoms directed toward others, or behavior symptoms not directed at others such as pacing. R2 was identified as having impairment of both lower extremities and noted to use 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 observation, interview, and record review, the facility failed to consistently communicate with dialysis department, and follow through on directions for 1 of 1 residents (R141) reviewed for dialysis Findings include: R141 was admitted to the facility on [DATE]. R141's brief interview for mental status assessment completed on 4/17/25, indicated he was cognitively intact. R141's diagnoses upon admission to the facility included end stage renal (kidney) disease, congestive heart failure, diabetes (a condition where the body has problems with regulating blood glucose (sugar), and post surgical treatment of left foot. A provider visit note of 4/18/25, identified: R141 was admitted following recent hospitalization for surgery to his left foot. The note also identified R141 had been hospitalized for nausea and vomiting after dialysis, with hypotension (low blood pressure) during dialysis, dark stools requiring EGD (a scope to view digestive system) (showing gastroparesis), and mild hypoglycemia (low blood…

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 observations, interviews and document review, the facility failed to ensure resident medical social services were provided for 2 of 2 residents (R8 and R14) whose room odors permeated the surrounding halls. This had the potential to affect residents in surrounding rooms, visitors and facility staff. Findings include: R8 In review of R8's Diagnosis Report (print date 4/30/25) documented the diagnoses of morbid obesity with alveolar hyperventilation (a condition where the lungs don't move enough air in and out, leading to a buildup of carbon dioxide (hypercapnia) and a decrease in oxygen levels in the blood, and type 2 diabetes. R8's 5-day minimum data set (MDS - post hospitalization), dated 2/12/25, indicated R8 was independent with self cares, requiring partial/moderate assistance with toileting and substantial/maximal assistance with showering/bath. In review of R8's Brief Interview for Mental Status (BIMS), resident was assessed to be cognitively intact. During screening interview on 4/28/25 at 2:12…

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 1 of 5 residents (R5) reviewed for immunizations were offered and/or provided the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 10/24, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R5's face sheet dated 5/1/25, indicated she was [AGE] years old. The immunization record dated 5/1/25, indicated R5 received the following 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and document review, the facility failed to ensure resident living areas are free from odors for 2 of 2 residents (R8 and R14) in the sample whose room odors permeated the surrounding halls. This had the potential to affect residents in surrounding rooms, visitors and facility staff. In addition the facility failed to fully investigate missing personal items for 1 of 1 residents (R9) with reports of missing clothing that was reported missing for approximately two months. Findings include: R8 In review of R8's Diagnosis Report (print date 4/30/25) documented the diagnoses of morbid obesity with alveolar hypoventitlation {a condition where the lungs don't move enough air in and out, leading to a buildup of carbon dioxide (hypercapnia) and a decrease in oxygen levels in the blood}, and type 2 diabetes. R8's 5-day Minimum Data Set (MDS) - post hospitalization, dated 2/12/25, indicated R8 was independent with self cares, requiring partial/moderate assistance with toileting 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 Enhanced Barrier Precautions (EBP) were used for 1 of 3 residents (R3) reviewed for wound care. Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], listed the following diagnoses: cancer, anemia, hypertension (high blood pressure), renal insufficiency (kidneys do not filter the blood properly, dementia (loss of memory and abilities that interfere with daily life), multiple sclerosis (autoimmune disease that affects gait a fine motor skills) and depression. R3's physician order list accessed 3/19/25, indicated that following orders: -Wound Right Heel dated 3/14/25, ordered cleanse with wound cleanser, pat dry. Apply betadine every day and as needed. Offload with offloading boot. -EBP dated 2/21/25, ordered follow EBP while providing wound cares and other high contact care activities every shift. R3's care plan dated 2/21/25, indicated R3's was currently on EBP precautions related to wounds, and staff were to 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.

Based on observation and interview, the facility failed to ensure 1 of 3 residents (R5) room was kept clean to reside in. Furthermore, the facility failed to maintain sanitary condition in the dining room. This had the potential to affect all 24 residents who ate food in the dining room. Findings include: During observation on 2/20/2025 10:34 a.m. to 11:35 a.m., a significant size of brownish stains were observed on the floor under a table close to the kitchen on three spots in the dining room. R5 stated it looked gross. Also observed were a few soiled tissues on the floor, uncleaned plate on two tables in the dining room with rest of scrambled eggs and pieces of bread. Six residents sitting two by two at the tables in the dining room. During observation on 2/20/25 at 11:42 a.m., the housekeeping supervisor (HS)-A cleaned the brownish stains under the table using washcloths without gloves on and then walked out of the dining room, did not wash hands, and touched a resident at the door who was asking for water. On 2/20/25 at 2:15 p.m. (HS)-A stated she was busy today and was not able…

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 personal protective equipment (PPE) was utilized for 3 of 4 residents (R1, R2, R4) reviewed for infection control concerns. Furthermore, the facility failed to ensure enhanced barrier precaution (EBP) [measure intended to prevent the spread of multi drug-resistant organisms] was implemented for 2 of 4 residents (R1, R4) reviewed for foley catheter cares. Findings include: R1 R1's admission Record dated 6/21/2023, indicated R1's diagnoses included urinary tract infection, sepsis, and retention of urine. R1's quarterly Minimum Data Set, dated [DATE], indicated R1 had intact cognition and required moderate assistance of two persons with an easy stand (EZ) for transfers. R1's care plan dated 12/20/24 indicated R1 had foley catheter, moderate assist for toilet hygiene with staff interventions included follow EBP direction while providing urinary catheter maintenance, contact with the catheter, tubing, collection bag, and other high…

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's ordered medications were fully communicated to the filling pharmacy. In addition, the facility failed to ensure all licensed staff (including pool agency staff) understood and utilized the emergency medication kit (E-Kit) for 1 of 3 residents (R1) who did not have all physician ordered medications delivered from pharmacy for continuity of care. Findings include: R1's Active Diagnosis listing documented the following diagnoses: acute and chronic congestive heart failure, type 2 diabetes (insulin dependent), asthma and morbid obesity due to excess calories. R1's minimum data set (MDS) was still in process due to R1's admission on [DATE]. However, the facility had performed a Brief Interview for mental Status (BIMS) with R1, dated 12/24/24 and found to have scored 15 (cognitively intact). In review of R1's Clinical Profile (Face Sheet), R1 was admitted to the facility on [DATE] form Ridgeview Hospital Waconia. The hospital…

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 notify the resident's representative following resident change of condition for 1 of 1 resident (R1) who had a decline in condition resulting in hospitalization. Findings include: R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment. R1's diagnoses included diabetes, morbid obesity, anemia, edema, heart failure, altered mental status, and end stage renal disease. R1 was dependent on staff for dressing, toileting, personal hygiene, transferring, and bed mobility. The MDS also identified R1 had two stage 2 pressure ulcers (presenting as a shallow open ulcer); three stage 3 pressure ulcers (full thickness tissue loss which may include undermining or tunneling) and one unstageable pressure ulcer (known but not stageable due to coverage of wound bed by slough and/or eschar). R1's physician orders included: - Tylenol 1000 mg by mouth three times daily for pain; Tramadol 50 mg by mouth every six hours as…

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 effectively monitor and communicate wound status for early recognition of changes on 1 of 2 residents (R1) reviewed for worsening pressure ulcers. Findings include: R1's significant change in status Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment. R1's diagnoses included diabetes, morbid obesity, anemia, edema, heart failure, altered mental status, and end stage renal disease. R1 was dependent on staff for dressing, toileting, personal hygiene, transferring, and bed mobility. The MDS also identified R1 had two stage 2 pressure ulcers (presenting as a shallow open ulcer); three stage 3 pressure ulcers (full thickness tissue loss which may include undermining or tunneling) and one unstageable pressure ulcer (known but not stageable due to coverage of wound bed by slough and/or eschar). R1's care plan initiated on 8/16/23, indicated R1 had skin alterations to coccyx, rear right thigh, left 2nd toe, and left heel.…

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 notify the attending physician of a change in condition for 1 of 1 resident's (R42) reviewed for new onset of hallucinations and delusions. Findings include: R42's admission minimum data set (MDS) dated [DATE], identified severe impairment in cognition with no hallucinations or delusions and diagnoses of myocardial infarction (heart attack), heart failure, gastrointestinal hemorrhage, and anemia. Hospital discharge orders dated [DATE], indicated resident was hospitalized related to confusion and condition was improving. Therapy orders for occupational, physical therapy and rehabilitation potential was good. Care plan dated [DATE], instructed staff to monitor for lethargy and increased confusion. Progress note dated [DATE] at 5:55 p.m., identified R42 admitted to the facility with a discharge plan to return home after therapies. Progress note dated [DATE] at 10:18 p.m., indicated R42 was hard to arouse and slept all shift. Progress note dated [DATE]…

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 follow the interventions for 1 of 1 residents (R34) reviewed for weight loss and nutrition leading to a 15 lbs (8.37%) weight loss over the course of 47 days. Findings include: R34's admission record dated 12/26/2023, indicated medical diagnoses of vascular dementia, severe with agitation; anxiety disorder; moderate protein calorie malnutrition. R34's admission weight was noted to be 125.5 lbs. on 12/16/23. R34's weight on 1/31/24 was 115 lbs., indicating an 8.37% weight loss over the course of 47 days. R34's care plan listed potential for altered nutrition status related to need for mechanically altered diet related to dysphagia; and Potential for weight loss related to altered oral intakes as evidenced by malnutrition diagnosis. Interventions indicated R34 needed staff assistance with eating and drinking. R34's record of meal intake indicated resident refused or had eaten less than 25 % of her meal for 62 out of 100 meals served from 12/26/23 through 2/7/2024. During observation on 2/5/24 at 5:22 p.m., R34…

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 residents were free of significant medication errors for 1 of 1 (R94), residents reviewed for medication orders and administration. Findings include: R94's admission minimum data set (MDS) dated [DATE], identified intact cognition, diagnoses of manic depression, bi-polar, and antipsychotic medication. admitted to the facility 9/15/23 for short term therapy following hospitalization for bi-lateral pulmonary embolisms and falls. R94's hospital discharge orders dated 9/15/23, identified an order for aripiprazole (an antipsychotic medication) 30 milligrams (mg) take 30 mg by mouth once daily for manic depression. R94's facility discharge order summary report dated 11/14/23 identified an order for aripiprazole give 30 mg by mouth two times a day (bid) related to major depressive disorder with a start date of 9/15/23. This dose is double the order identified in R94's hospital discharge orders. R94's medication administration records 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 store food in accordance with professional standards for food service safety, monitoring of refrigerator/freezer temperatures and performing proper hand hygiene during meal services. This had the potential to affect all residents, staff and visitors who ate at the facility. Findings include: On 4/2/23, at 11:50 a.m. an initial kitchen tour was completed with lead cook (cook)-A. The following areas of concern were identified. -In walk in cooler the following food items were expired and/or not labeled with dates: container of sliced Swiss cheese, with corner of container open to air, was dated 12/1 and there was approximately 6 slices of cheese that had a white powdery substance on the cheese, cook-A stated, yes it's moldy; container of coleslaw with no open date labeled on container; French onion dip labeled 2/6/23; bag of tomatoes with no date; bag of cooked bacon with no date; container of strawberries dated 2/14; open bag of sliced…

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 3 of 5 residents (R10, R25, and R32) reviewed for COVID-19 vaccination status were offered the COVID-19 vaccine, and/or provided education regarding the risks, benefits, and potential side effects of COVID-19 vaccinations in accordance the Centers for Disease Control and Prevention (CDC) recommendations. Findings include: R10's face sheet dated 4/3/23, indicated R10 had been admitted to the facility in January 2023. R10's medical record lacked evidence of COVID-19 vaccination, education, contraindication, and/or documentation of refusal by the resident or resident representative. Vaccination status had been reviewd for R10 with current immunizations scanned in from Minnesota Immunization Information Connection (MIIC). After Additional records were requested 4/3/23, the administrator provided declination form on 4/4/23 signed by resident and dated 4/3/23 after the survey enterance and after requested by the surveyor. R25's face sheet dated 4/3/23, indicated R10 had been admitted to the facility in March 2023. R25's…

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 notify the medical provider and resident representatives of weight loss for 1 of 1 resident (R25) reviewed for notification of change. Findings include: R25's admission Minimum Data Set (MDS) dated [DATE], identified R25 had severe cognitive impairment and was not able to clearly communicate his needs and wishes. Further, R25 required extensive assistance for his activities of daily living (ADL's) and had several medical diagnoses including expressive language disorder (communication disorder in which there are difficulties with verbal and written expression), dysphagia (difficulty in swallowing food or liquid), chronic kidney disease, stage 4 (severe) (gradual loss of kidney function), dietary calcium deficiency, retention of urine, hypokalemia (low levels of potassium), hypomagnesemia (low levels of magnesium), essential hypertension (high blood pressure) and heart failure (a progressive heart disease that affects pumping action of 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 ensure confidential information was not readily available for all residents, staff, and visitors to view for 1 of 1 resident (R192) observed to have private information visible on an open computer screen in a common area. Findings include: R192's admission Minimum Data Set (MDS) dated [DATE], indicated R192 was cognitively intact and was able to clearly communicate her needs and wishes. The MDS indicated R192 required limited to extensive assistance with all activities of daily living (ADL). During continuous observation on 4/4/23, from 3:23 p.m. to 3:33 pm R192's picture and medications were displayed on an open computer screen that was left unattended on the nurse's medication cart in the common area by nurse's station. At 3:23 p.m. computer screen, on med cart, was open with R192's personal information visible on screen. At 3:24 p.m. another resident and her husband walked past the med cart and looked in the direction of the open…

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 pressure ulcer interventions for 1 of 1 resident (R25) identified at risk for pressure ulcers. Findings include: R25's admission Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment with diagnosis including aphasia (difficulty speaking), dysphagia (difficulty swallowing), a stroke, kidney failure, low blood potassium, low blood sodium, and heart failure. R25 required extensive assistance with mobility and did not have any pressure ulcers. R25's care plan dated 3/7/23, identified alteration in skin integrity and directed staff to apply protector on left heel when resident was in bed, monitor skin integrity daily during cares with weekly inspection by nurse, treatment to open areas per order, turn and reposition or reminders to offload q (every) 2-3 hours and PRN (as needed), pressure redistribution mattress to bed, pressure redistribution cushion to w/c (wheel chair) and chair, weekly measurements 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 residents received appropriate ongoing catheter care that adhered to professional standards of practice and infection prevention for 3 of 3 residents (R33, R22, R25) who were reviewed for indwelling urinary catheter use. Findings include: R33's significant change Minimum Data Set (MDS) dated [DATE], indicated he had moderately impaired cognition, an indwelling urinary catheter and required extensive assist of 2 with toileting and personal hygiene. R33's Waconia Ridgeview Hospital Interagency Referral Form dated 2/10/23, indicated an indwelling urethral catheter for urinary retention was placed during his inpatient hospitalization prior to returning to the facility on 2/10/23. R33's care plan dated 2/16/23, indicated the presence of an indwelling catheter and directed staff to, change catheter per physician order and when needed, to position catheter bag and tubing below the level of the bladder, to monitor and document intake 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 complete accurate assessments, interventions and ongoing weight monitoring, meal refusal monitoring and availability of fluids to address unplanned weight loss for 1 of 1 resident (R25) reviewed for nutrition and hydration. Findings include: R25's admission Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment, an inability to communicate needs, required extensive assist for most activities of daily living (ADL's). R25 required supervision, oversight, encouragement or cueing along with set up help for eating. R25 weighed 207 pounds and did not have any known weight loss or gain in the prior 6 months. R25 had received speech-language pathology services during the assessment period. R25 did not reject cares. It was somewhat important to R25 to have snacks available between meals. R25's diagnoses included, a stroke with aphasia (difficulty speaking), and dysphagia (difficulty swallowing), low blood sodium, diabetes…

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, document review and interview, the facility failed to ensure supply and administration of ordered medications for 2 of 2 residents (R35 and R20) reviewed for pharmacy services. Findings include: R35's quarterly Minimum Data set (MDS) dated [DATE] indicated he was cognitively intact and had a diagnosis of anxiety. R35's Care Area Assessment worksheet dated 10/27/22, indicated Psychotropic drug use and staff will continue to follow plan of care to aide in prevention and manage any potential negative outcomes related to meds including admin [administration] meds [medications] as ordered, R35's Diagnosis Report dated 4/6/23, indicated he had panic disorder and general anxiety disorder. R35's care plan focus dated 9/11/22, indicated he had an alteration in mood and behavior due to diagnoses of major depressive disorder and anxiety disorder and directed staff to provide medications per order. R35's provider visit notes dated 2/14/23, indicated he continues to report significant issues with…

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 pharmacist consultant recommendations were acted upon for 1 of 5 residents (R33) reviewed for unnecessary medications. Findings include: R33's significant change in status Minimum Data Set (MDS) dated [DATE] indicated he had moderately impaired cognition, was frequently incontinent of bowel, had a diagnoses including, Parkinson's Disease and psychotic disorder and received antipsychotics and antidepressant medications. R33's Consultant Pharmacist's Medication Review dated 11/5/22, indicated a recommendation to place standing orders for orthostatic blood pressures every month related to anti-psychotic use. The medication review indicated antipsychotics could cause orthostatic hypotension. R33's physician orders dated 4/2/23, indicated he was receiving the anti-psychotic medication Quetiapine Fumarate 12.5 mg (milligrams) two times a day for Psychosis related to Parkinson's Disease. R33's orders also indicated to monitor orthostatic blood…

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 2 of 5 residents (R10 and R32) admitted during the 2022/2023 influenza season (October 1 through March 31) received the influenza vaccination in accordance with the Center for Disease Control (CDC) recommendations. Findings include: R10's face sheet dated 4/3/23, indicated R10 had been admitted to the facility in Jaunary 2023. R10's medical record lacked evidence of influenza immunization, education, contraindication, and/or documentation of refusal by the resident or resident representative. Vaccination status had been reviewd for R10 with current immunizations scanned in from Minnesota Immunization Information Connection (MIIC). After additional records were requested, the administrator provided a declination form signed by resident dated 4/3/23 after the start of the survey and after requested by the surveyor. R32's face sheet dated 4/3/23. Indicated R32 had been admitted to the facility in February 2023. R32's medical record lacked evidence of influenza immunization, education, contraindication, and/or…

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.