The Waterview Pines LLC

Inspectors wroteBased on interview and document review, the facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight hours a day. This had the potential to affect all 67 residents who resided at the facility. This was at past non-compliance do to no RN coverage addressed in the last two quarterly staffing records.

Inspectors wroteBased interview and record review the facility failed to ensure psychotropic PRN (as needed) medication orders were timed limited to a duration of 14 days for 1 of 5 residents (R9) who was reviewed for psychotropic medications.

Inspectors wroteBased on observation, interview and document review, the facility failed to review and revise the resident care plan to include chemotherapy, breathing problems and oxygen use for 1 of 3 residents (R31) reviewed for care planning. R31's quarterly minimum data set (MDS), dated [DATE], identified a diagnosis of congestive heart failure (CHF), rectal cancer, and atrial fibrillation. R31's care plan, dated 12/11/25, didn't contain a focus statement for coordination and care of R31's chemotherapy treatments, breathing problems or oxygen use. R31's provider orders, dated 1/12/26, didn't contain orders for oxygen use or the care and keeping of oxygen equipment. R31's Weights and Vitals Summary identified R31 was wearing oxygen via nasal cannula on dates when oxygen saturation levels were recorded starting on 10/29/25 through 1/15/26. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a resident who was unable to perform their own activities of daily living (ADL)s received nail care for 1 of 3 residents (R44) reviewed for ADLs. R44's quarterly minimum data set (MDS), dated [DATE], identified significant cognitive impairment and a diagnosis of late-onset Alzheimer's dementia. The MDS further indicated R44 was dependent in all ADLs. R44's care plan, dated 8/6/25, identified a focus statement for assistance with ADLs related to dementia, osteoarthritis, weakness and falls. Interventions included an assist of one with all ADL tasks including nail care, specifically to trim fingernails and toenails as needed on shower days. The care plan didn't include podiatry care for her toenails, nor did it address behavior or resistance to having nails trimmed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure orders were in place for a resident receiving oxygen for 1 of 7 residents (R31). In addition, the facility failed to assess and treat lower extremity edema for 1 of 7 residents (R23) reviewed for quality of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure portable oxygen tanks were safely transported and/or secured for 1 of 2 residents (R23) reviewed for oxygen safety.

Inspectors wroteBased on interview and document review the facility failed to monitor fluid intake for a resident on a fluid restriction and on dialysis. This effected 1 of 2 (R8) residents reviewed for dialysis.

Inspectors wroteBased on observation, interview and document review the facility failed to perform appropriate hand hygiene while doing a brief change. The facility also failed to utilize appropriate personal protective equipment (PPE) for a resident in enhanced barrier precautions. This affected 2 of 5 resident (R54, R6) reviewed for infection control.

Inspectors wroteBased on interview and document review, the facility failed to ensure the past three years of recertification and complaint survey results were available for review. This had the potential to affect all 67 residents residing in the facility, as well as family, visitors and staff.

Inspectors wroteBased on observations, interviews, and record review the facility failed to promote dignity and respect for 1 of 3 residents (R1) who required assistance with activities of daily living (ADLs) and reported rough and disrespectful care by staff.

Inspectors wroteBased on interviews and document review the facility failed to thoroughly investigate an allegation of staff to resident abuse and protect residents during the investigation for 1 of 3 residents (R1) who reported a staff handled their care roughly, causing them pain.

Inspectors wroteBased on observation, interview and document review the facility failed to develop and implement a procedure to determine appropriate sling types for 3 residents (R1, R2, R3) assessed to require the use of mechanical lift for transfers. This resulted in a fall from a ceiling lift resulting in non-surgical fractures and a head laceration for R1 and observation of the wrong sling size, sling type in their room or being used by staff for R2 and R3. This resulted in immediate jeopardy (IJ) for R1, R2 and R3. The immediate jeopardy began on 8/1/25, when R1 fell while being transferred in a full body mechanical lift and fell out of the lift during transfer, resulting in a serious injury. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure equipment was not broken for 1 of 1 resident (R25) reviewed for environment.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, document review, and interview the facility failed to ensure required nurse staffing information was posted daily over the weekend, this deficient practice had the potential to impact all 53 residents residing at the facility and visitors who may wish to review this information.

Inspectors wroteBased on interview and document review, the facility failed to provide adequate supervision for 1 of 3 residents (R1) who was at risk for elopement. This resulted in an immediate jeopardy (IJ) for R1 when she eloped from the facility, and was found outside after an indeterminable amount of time. The facility implemented corrective action prior to the investigation so the deficiency was issued at Past Noncompliance. The IJ began on 3/10/24 at 11:00 a.m. when dietary aide (DA)-A discovered R1 outside of the facility on the sidewalk, approximately 30 feet from the door. Weather Underground identified the temperature in Virginia, MN was 19 degrees Fahrenheit (F) at 10:53 a.m. The administrator and director of nursing (DON) were informed of the IJ on 3/20/24 at 4:10 p.m. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]