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
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 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 REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/12/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
The Waterview Pines LLC
1201 8th Street South Virginia, MN 55792
SUMMARY STATEMENT OF DEFICIENCIES
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.)
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/12/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
The Waterview Pines LLC
1201 8th Street South Virginia, MN 55792
SUMMARY STATEMENT OF DEFICIENCIES
During observation on 8/6/25 at 4:13 p.m., NA-C and NA-D prepared to transfer R3. R3 was lying in bed and had a toileting sling underneath her. NA-C and NA-D switched the sling for a full body sling as directed in the care plan. NA-C stated the sling underneath R3 was not the correct sling. NA-D said the staff on the previous shift had used the wrong sling to transfer R3.
During interview on 8/7/25 at 10:43 a.m., registered nurse (RN)-A stated slings were assessed on admission, quarterly and with a change of condition. RN-A stated sling size and type were based on height and weight of the resident and said sling type was based on whether the resident was continent or not. RN-A said a toileting sling would not be used if there were physical limitations such as an amputation or if the resident was agitated or displayed behaviors and could go through the sling. RN-A said the toileting sling was appropriate for R1 even though R1's Lift form indicated she was unable to follow simple instructions and was not cooperative with transfers, because R1 still used the toilet.
Facility Policy [NAME] Patient Handling dated 3/2020, indicated safe patient handling is a key component to providing employees a safe work environment, while providing high quality resident care.
Specifically, 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 necessary.
All resident care will be provided in a safe, appropriate and timely manner in accordance 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.
Facility ID: