The Waterview Pines Llc
THE WATERVIEW PINES LLC in VIRGINIA, MN — inspection on August 12, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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 been reported to the SA because the care plan had been followed during the transfer.
During interview on 8/7/25 at 8:44 a.m., the facility's ceiling lift representative (R)-A stated typically when an accident happened during transfer in a lift, something would have been wrong with the way the sling was used or applied. R-A said the toileting slings used with the ceiling lift required the resident to keep their arms outside the sling. R-A said with the toileting sling, size was a much bigger deal because there was more open area. R-A stated if a resident did not have the cognitive or physical ability to keep their arms outside the sling, the toileting sling would not be recommended. R-A said if the sling used during transfer was appropriate for the resident, a fall from the lift should not have happened.During interview on 8/7/25 at 9:00 a.m., nursing assistant (NA)-A stated she had been transferring R1 from the wheelchair to the bed, not from the toilet, and said during the transfer, R1 put her arms through the sling and had been confused and tired. NA-A said R1 had been resting her hands on her legs on her lap. NA-A said she had watched R1 put her arms inside the sling and had told her to keep her arms outside the sling. NA-A said she tried to catch R1 when she fell and they both fell.
She said the wheelchair was positioned parallel to the bed with a floor mat between the bed and the chair but said R1 had landed on the floor at the end of the bed. NA-A said she had used the correct sling size and had used the toileting sling.
However, R1's care plan directed the use of a full body sling for transfers when not using the toilet.Facility policy Abuse Prohibition/Vulnerable Adult dated 4/2025, indicated all staff are responsible for reporting situation that is considered abuse or neglect, defined as the facility failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.
Suspected abuse shall be reported to the SA no later than two hours after forming the suspicion of abuse.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
245283 08/12/2025
The Waterview Pines LLC 1201 8th Street South Virginia, MN 55792
Investigation may include interviews with staff, residents or other witnesses to the event.
Corrective action based on the investigation will be completed (e,g,, change of procedure, training, discipline or discharge of staff, etc.)
245283 08/12/2025
The Waterview Pines LLC 1201 8th Street South Virginia, MN 55792
and was not cooperative with transfers, because R1 still used the toilet.
Facility Policy [NAME]
jeopardy to resident health or employees a safe work environment, while providing high quality resident care.
Specifically, safety mechanical lift equipment and/or other approved patient moving aides/devices should be used in all circumstances when liftin/moving residents except when manual assistance is deemed absolutely
with the residents plan of care.
The immediate jeopardy began on 8/1/25.
The immediate jeopardy was removed 8/8/25, after the facility implemented a systemic plan that included the following actions: - Developed and implemented a system to determine appropriate sling size/use based on resident need and manufacturer's guidelines for R1, R2, and R3.-Assessed all residents who required the use of an assistive device to ensure correct sling was in use.-Ensured staff were educated to that process and where to find information regarding accurate sling per resident.- Developed a procedure related to assessment of resident sling use.-Educated staff responsible for transferring residents to the above policies, procedures, and changes made prior to the beginning of their next shift.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.