First Care Living Center

In the surveyor’s words

From the most serious findings on record at First Care Living Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF600Jul 15, 2021

  Based on interview and document review, the facility failed to report allegations of abuse to the state agency (SA) as required; provide resident protection during investigation for 4 of 4 residents (R3, R4 R2, R1) reviewed for allegations of staff to resident abuse. This resulted in an immediate jeopardy (IJ) situation for R3, R4 R2, R1 who all had allegations of abuse by the same nursing assistant and the facility failed to provide protection from ongoing abuse and had the potential to all residents residing in the facility. The IJ began on 3/7/21, when it was reported nursing assistant (NA)-A and NA-B used profanity and called R3 names, this was not reported to the SA and the residents were not provided immediate protection from further abuse. […]

• Immediate jeopardy, isolatedF689Apr 26, 2024

  Based on observation, interview and document review the facility failed to ensure safe transfer while utilizing a mechanical lift for 1 of 3 residents (R1) reviewed for accidents. This resulted in an immediate jeopardy (IJ) for R1. The immediate jeopardy began on [DATE], when R1 fell while being transferred in a full body mechanical lift that tipped over during provision of care. The facility failed to identify if the staff were correctly using the lift per manufacturer recommendation when the incident occurred. Additional transfer observations identified manufacturer's guidelines were not followed for safe use. The IJ was identified on [DATE]. The administrator and director of nursing (DON) were notified of the immediate jeopardy at 5:05 p.m. on [DATE]. […]

• Immediate jeopardy, isolatedF689May 22, 2023

  Based on observation, interview and document review, the facility failed to evaluate and analyze hazards following a resident fall from a Hoyer lift resulting in a laceration to the elbow and hematoma on the head. A second, near miss incident occurred one week later for the same resident (R1) using the same lift. This resulted in an immediate jeopardy for R1. The immediate jeopardy began on 5/9/23, when R1 fell from the Hoyer lift during provision of care. The facility failed to thoroughly investigate and identify if the staff were correctly using the lift per manufacturer recommendation when the incident occurred. The IJ was identified on 5/19/23. The administrator and director of nursing (DON) were notified of the immediate jeopardy at 12:34 p.m. on 5/19/23. […]

• No harm, potential for more than minimal, widespreadF607Jul 15, 2021

  Based on interview and document review, the facility failed to ensure their abuse prohibition and prevention policy included the federal requirements related to reporting, protection and investigation. This had potential to affect all 34 residents residing in the nursing home at the time of the survey. Findings include: The facility Essentia Health Fosston Vulnerable Adult Policy and Procedure dated June 2017, indicated Essentia Health Fosston should establish and enforce an ongoing abuse prevention plan. The plan should contain an assessment of the physical plant, environment and it's population identifying factors which may encourage or permit abuse and a statement of specific measures to be taken to minimize the risk of abuse. […]

• No harm, potential for more than minimal, patternF883Aug 17, 2023

  Based on interview and document review, the facility failed to provide the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine for 4 of 5 residents (R14, R20, R27, R34) reviewed for immunizations. Findings include: R14's quarterly MDS dated [DATE], identified R14 was admitted to the facility on [DATE], was [AGE] years old and identified a diagnosis of diabetes. R14's Preventative Health Care immunization record undated, identified R14 received the PPSV23 on 10/6/04 and 20/20/19. […]