Harmony River Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hutchinson, Minnesota.
- Location
- 1555 Sherwood Street Southeast, Hutchinson, Minnesota 55350
- CMS Provider Number
- 245114
- Inspections on file
- 20
- Latest survey
- April 7, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Harmony River Living Center during CMS and state inspections, most recent first.
A resident with a history of behavioral disturbances and cognitive impairment made multiple allegations of physical and sexual abuse. Although facility policy required reporting such allegations to the state agency within two hours, staff and administrators did not consistently follow this protocol, often choosing not to report due to the resident's history of frequent allegations. This resulted in a failure to meet mandated abuse reporting requirements.
A resident with mild cognitive impairment and a history of behavioral disturbances made multiple allegations of physical and sexual abuse. Despite these reports and the facility's policy requiring formal investigation of all abuse allegations, staff did not initiate a formal investigation, citing the resident's history of similar claims and existing preventive measures such as the buddy care system.
A resident with CHF and renal insufficiency missed twelve doses of Bumex due to the medication being unavailable, while still receiving potassium chloride. Multiple staff were aware of the issue but did not consistently follow protocol for medication unavailability or notify the physician in a timely manner. The resident developed symptoms including shortness of breath and confusion, ultimately requiring hospitalization for CHF and hyperkalemia.
A facility failed to update a comprehensive care plan for a resident with pneumonia and respiratory failure. The resident's MDS indicated these conditions, but the care plan lacked specific interventions. A nurse acknowledged the oversight, and the DON stated that care plans should reflect resident needs. Facility policy required updates with each MDS assessment, which was not followed.
A resident with moderate cognitive impairment and extensive tremors required assistance with eating but was consistently served last, leading to delays in receiving help. Staff confirmed that residents needing assistance were served after independent residents, contrary to the facility's policy for dignified and prompt meal service.
A resident on a diet requiring mild thickened liquids due to aspiration risk was given non-thickened water, contrary to prescribed dietary orders. Despite care plans and facility sheets indicating the need for thickened liquids, staff failed to provide the correct consistency, leading to a deficiency. Interviews confirmed the resident's dietary needs and the facility's policy on thickened liquids for swallowing difficulties.
Failure to Timely Report Allegations of Abuse to State Agency
Penalty
Summary
The facility failed to report allegations of abuse to the state agency within the required two-hour timeframe after the allegations were made. One resident, who had a history of behavioral disturbances, paranoia, delusions, and making previous allegations against staff, reported multiple incidents of being struck on the head and being touched inappropriately during the night. Documentation in the resident's care plan indicated that staff were to implement a buddy care system for all care tasks and report any further concerns to the campus administrator, following the facility's vulnerable adult policy. Despite these documented allegations, interviews with staff revealed inconsistent practices regarding the reporting of abuse. Some staff members stated they would notify the nurse or administrator immediately upon hearing an allegation, while others indicated that the resident's history of making frequent allegations influenced whether or not the incidents were reported to the state agency. The household coordinator specifically stated that not all of the resident's allegations were reported to the state agency due to their frequency. The administrator and clinical leadership described a process of vetting allegations based on the resident's care plan and history, sometimes choosing not to report if the care plan was followed or if the resident had a known history of making such claims. Facility policy required that allegations of abuse be reported within two hours, but the actual practice did not consistently meet this standard, resulting in a failure to comply with federal and state reporting requirements.
Failure to Investigate Abuse Allegations for High-Risk Resident
Penalty
Summary
The facility failed to conduct a formal investigation into multiple allegations of physical and sexual abuse made by a resident with mild cognitive impairment, chronic pain, and a history of behavioral disturbances, paranoia, and delusions. The resident, who required substantial assistance and used a wheelchair, reported on several occasions that he had been struck on the head and touched inappropriately. Documentation shows that staff were aware of the resident's history of making abuse allegations and had implemented a buddy care system as a preventive measure. Despite these safeguards and the resident's repeated reports, staff responses were limited to documentation and internal notifications, without initiating a formal investigation as outlined in facility policy. Interviews with nursing and administrative staff revealed that the decision not to formally investigate was based on the resident's history of making similar allegations, the presence of the buddy care system, and the belief that no other residents could have entered the room. The facility's Vulnerable Adult Abuse Prevention Plan required a review and formal investigation of each allegation, including completion of an Investigation Form and staff interviews. However, these steps were not taken in response to the resident's reports, and the interdisciplinary team determined that a formal investigation was unnecessary, contrary to facility policy.
Failure to Administer Ordered Medication Resulting in Hospitalization
Penalty
Summary
A deficiency occurred when a resident with a history of congestive heart failure (CHF), atrial fibrillation, and renal insufficiency did not receive twelve doses of Bumex, a diuretic prescribed to manage fluid retention associated with CHF. The medication was ordered to be administered twice daily, but starting with a noon dose, the medication was not available and was not given for several consecutive days. Despite the absence of Bumex, the resident continued to receive potassium chloride as ordered, which is significant because Bumex can cause potassium loss, and the potassium supplement was intended to counteract this effect. Documentation and interviews revealed that multiple staff members, including trained medication assistants (TMAs) and nurses, were aware that the medication was unavailable. Some staff attempted to reorder the medication and notified others, but there was a lack of consistent follow-up and communication. The facility's protocol required staff to check backup storage, contact the pharmacy, notify the clinical coordinator, and inform the physician if a medication was unavailable. However, these steps were not consistently followed, and the physician was not notified of the medication's unavailability until several days after the first missed dose. During the period when the resident was not receiving Bumex, she exhibited symptoms such as shortness of breath, confusion, restlessness, and weight gain. The situation escalated to the point where the resident was hospitalized for acute and chronic CHF and hyperkalemia, with a critical potassium level documented. The failure to administer Bumex as ordered and to follow established protocols for medication unavailability directly contributed to the resident's decline and subsequent hospitalization.
Failure to Update Care Plan for Resident with Respiratory Conditions
Penalty
Summary
The facility failed to create a comprehensive care plan for a resident with a history of respiratory conditions. The resident, identified as R102, had diagnoses of pneumonia and respiratory failure, as indicated in their Medicare 5-day Minimum Data Set (MDS). However, the resident's care plan was undated and lacked specific interventions related to these respiratory conditions. During an interview, a registered nurse acknowledged that the care plan should have been updated with a respiratory care plan, goals, and interventions when the MDS was updated. The director of nursing stated that the care plan should be filled out based on resident needs. The facility's policy indicated that care plans should be reviewed with each MDS assessment and updated as the resident's condition changes, but this was not adhered to in R102's case.
Failure to Provide Timely Eating Assistance
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADL) for a resident who required help with eating. The resident, identified as R38, had moderate cognitive impairment and required assistance with all ADLs due to extensive tremors. Observations on two separate occasions revealed that R38 was seated at a dining room table with two other residents who were served their meals first and began eating while R38 waited. On both occasions, R38's meal was served later, and assistance with eating was only provided after the other residents had started their meals. Interviews with staff, including a nursing assistant and the director of nursing (DON), confirmed that residents who required assistance with eating were served last. The DON acknowledged the importance of serving all residents at the same time for a more dignified and pleasurable dining experience. The facility's Dining Room Protocol policy indicated that staff should provide dignified and prompt meal service, but the practice of serving residents needing assistance last was contrary to this policy.
Failure to Follow Prescribed Dietary Orders for Resident
Penalty
Summary
The facility failed to adhere to prescribed dietary orders for a resident identified as R102, who was on a diet requiring mild thickened liquids due to increased risk of aspiration with thin liquids. Despite the care plan and facility care sheets indicating the need for mild thickened liquids, R102 was observed with a plastic glass containing non-thickened water, which the resident drank. This observation was confirmed by nurse assistant NA-D, who acknowledged that the water in both the plastic cup and a large gray mug was unthickened and should have been thickened before being given to the resident. Interviews with staff, including the speech language pathologist and the director of nursing, confirmed that R102 was placed on mild thickened liquids to mitigate the risk of aspiration. The facility's diet policy, last revised in March, stated that thickened liquids are recommended for residents with swallowing difficulties to reduce the risk of choking or coughing. However, the failure to follow these prescribed dietary orders resulted in a deficiency, as the staff did not ensure that R102 received the appropriate consistency of liquids as required by the care plan.
Latest citations in Minnesota
A resident with intact cognition and multiple diagnoses, including AFib, HF, stroke, anxiety, and depression, was permitted to self-administer nebulizer treatments after staff setup without an IDT self-administration assessment. The EMR lacked documentation of the resident’s competency and safety to manage the nebulizer, including understanding the medication, following directions, operating the equipment, recognizing side effects, and storing the medication and equipment. Staff and the DON confirmed the assessment had not been completed before the self-administration order was implemented.
Failure to Assess and Monitor Antipsychotic Use: A resident with severe cognitive impairment, dementia, anxiety, and mood disorder received Risperidone for agitation and paranoia, but the EMR did not show an AIMS assessment on admission or timely target behavior monitoring. The RN case manager and DON confirmed that baseline AIMS and ongoing behavior monitoring should have been in place when the antipsychotic was started, but the resident’s record lacked measurable target behaviors and documentation of medication effectiveness.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs: The facility failed to include key diagnoses, devices, and medication-related risks in care plans for two residents. One resident’s plan did not address Eliquis use, cardiac conditions, pacemaker presence, or condom catheter care, and another resident’s plan did not address Eliquis therapy or related bleeding-risk monitoring. The DON and RN case manager confirmed these items should have been care planned.
Failure to provide scheduled bathing and grooming assistance: Two residents with intact cognition and ADL dependence did not receive bathing as documented on a weekly schedule, and one resident also had unaddressed facial hair and greasy, unkempt hair. Records did not show consistent weekly baths, additional refusals, or reasons for missed care, and staff interviews confirmed residents were expected to receive at least weekly bathing unless they refused and that facial hair should be shaved when noticed.
A resident with intact cognition and multiple diagnoses, including BPH and stroke, had a physician order for a condom catheter at bedtime, but the EMR lacked orders or instructions for cleaning, disinfecting, monitoring, or changing the drainage bag. During observation, the bag was seen hanging in the bathroom, and an LPN, RN case manager, and DON all confirmed the absence of documented guidance for the catheter drainage bag care.
Failure to preserve dignity occurred when staff placed a brief on a cognitively intact resident who was continent of bowel and bladder. The resident stated the brief made him feel like a baby, and a NA confirmed she applied it even though he was not incontinent; RN and DON both verified the resident was continent and that briefs should not be placed on continent residents.
Failure to provide restorative ambulation and respond to a decline in mobility: A resident with dementia, weakness, chronic pain, and limited physical mobility was care planned for daily ambulation with a FWW and staff assist of 1, but the rehab record repeatedly showed ambulation as not applicable and staff interviews confirmed the task was often not done. The resident stated she could no longer walk, staff reported she had not walked for weeks and now required a sit-to-stand lift with assist of 2 for transfers, and the chart lacked an ADL decline assessment or revision of the ambulation care plan.
A resident with mild cognitive impairment, hemiplegia, hemiparesis, and limited ROM had restorative orders for PROM, stretching, and hand splints, but staff did not consistently offer or complete the interventions. Documentation showed the splints were sometimes marked not applicable instead of refused, and leg stretches were completed only a few times with no explanation for missed care. Staff interviews confirmed the restorative tasks often were not done, and the DON stated the resident’s restorative program needed to be updated.
Dirty can opener and contaminated dry storage bins: The DCS observed four labeled dry-goods bins with dirty rims, dry matter on the bin walls, and a scoop left inside a flour bin with flour on it. The attached can opener also had dry red matter on the blade, and the cook said it had been used that morning to open cream of corn for lunch. The DCS verified the findings and stated the can opener should be washed after each use and the dry bins and scoops should be kept clean.
Dignified Medication Administration Not Maintained: A resident with severe dementia, hallucinations, anxiety, PTSD, and delusional disorder was observed during med pass in the dining room. An RN attempted to administer meds by pouring them from a plastic cup into the resident’s mouth, continued despite the resident pulling away and moving her head, and then raised her voice and questioned why the resident would not take the meds after one pill was spit out and thrown on the floor. The resident stated the nurse was not being nice, and the RN left with the refused meds.
Missing Self-Administration Assessment for Nebulizer Use
Penalty
Summary
The facility failed to ensure an interdisciplinary team (IDT) assessment was completed before allowing a resident to self-administer nebulizer treatments. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders showed Ipratropium-Albuterol nebulizer treatments three times daily, and the EMR later included an order permitting the resident to self-administer nebulizer treatments after staff setup, but there was no evidence that an IDT self-administration assessment had been completed first. The record also lacked documentation showing the resident’s competency and safety to self-administer the nebulizer medication and treatment, including the ability to understand the medication purpose, follow directions, safely operate the equipment, recognize side effects or adverse reactions, and ensure safe administration and storage. During observation, the resident had nebulizer equipment and medication available in the room. The resident stated staff set up the medication cup and left while the treatment ran, then returned to ensure the machine was turned off; staff cleaned the nebulizer mask afterward. An LPN and RN confirmed the treatment was set up by staff, and the RN and DON stated a self-administration assessment should have been completed before the resident was permitted to self-administer medications.
Failure to Assess and Monitor Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications was adequately assessed and monitored. R3’s admission MDS identified severe cognitive impairment and the need for assistance with ADLs, with diagnoses including non-traumatic brain dysfunction, unspecified dementia without behavioral, psychological, mood, or anxiety disturbances, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder. The resident’s physician orders included Risperidone 0.25 mg, two tablets by mouth every four hours PRN for agitation and paranoia, with a maximum of three PRN doses in 24 hours, and Risperidone 0.5 mg, one tablet by mouth three times daily for paranoia/agitation. R3’s EMR did not show that an AIMS assessment was completed upon admission despite the resident receiving antipsychotic medication, and the assessment was only completed after surveyor request. The record also lacked evidence that target behavior monitoring had been initiated for the antipsychotic use, with no measurable target behaviors documented, including frequency, duration, severity, precipitating factors, or response to interventions for agitation and paranoia. Interviews with the RN case manager and DON confirmed that AIMS assessment and behavior monitoring should have been completed upon admission or initiation of antipsychotic medications, and both acknowledged that target behavior monitoring had not been initiated.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with significant medical conditions and medication-related needs. One resident had intact cognition and diagnoses including atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, depression, and a cardiac pacemaker, and was receiving Eliquis. The resident also had a physician order for a condom catheter at bedtime and removal when getting up for the day. The comprehensive care plan printed 5/20/26 did not identify interventions or monitoring related to anticoagulant use, including bleeding risk, adverse effect monitoring, or staff awareness of anticoagulant precautions, and it also lacked interventions related to the resident’s cardiac conditions, pacemaker, and condom catheter use, including skin integrity monitoring and resident-specific catheter care preferences. A second resident with severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, unspecified dementia, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder was also receiving Eliquis. The resident’s comprehensive care plan printed 5/19/26 did not include anticoagulant therapy, bleeding risk precautions, monitoring for adverse effects, or other interventions related to anticoagulant medication use. During interviews, the RN case manager and DON confirmed that anticoagulant therapy, the condom catheter, cardiac conditions, and pacemaker presence should have been addressed on the care plans and acknowledged that these items were not included.
Failure to Provide Scheduled Bathing and Grooming Assistance
Penalty
Summary
The facility failed to ensure that two residents who required assistance with activities of daily living received routine bathing and grooming services needed to maintain personal hygiene and dignity. R2’s MDS identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care while honoring personal hygiene preferences. R21’s MDS also identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care. R2’s bathing record showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. Baths were documented on several dates, but the time between some baths exceeded one week, and the record did not show additional refusals or reasons why scheduled baths were missed. During observation, R2’s hair was messy and greasy, and long white chin hairs were present. R2 stated she did not get baths very often because the facility was short staffed and said she did not have access to tweezers, a shaver, or a mirror. The EMR did not document that grooming assistance had been offered or provided for facial hair care. R21’s bathing record also showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. The record showed one refusal and several baths, but some intervals between baths exceeded one week, and there was no documentation of additional refusals or reasons for missed baths. R21 stated she had been in the facility since mid-April and had yet to have a bath or shower, and said staff were waiting for physician approval because of wounds, though that had been a while. R21 also stated she had only had her hair washed once with a shampoo shower cap while in bed. Staff interviews confirmed residents were expected to receive at least one bath weekly unless they refused, refusals should be documented, and facial hair should be addressed when noticed.
Missing Orders and Documentation for Condom Catheter Drainage Bag Care
Penalty
Summary
The facility failed to ensure appropriate care and services were provided for management of a resident’s external urinary catheter system. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders dated 4/29/26 indicated use of a condom catheter at bedtime, but the electronic medical record did not contain physician orders or documented instructions for cleaning, disinfecting, monitoring, or routinely changing the associated catheter drainage bag. During observation on 5/19/26 at 11:57 a.m., the resident’s catheter drainage bag was seen hanging on the side rail in the bathroom. Record review and observation did not identify documentation that the drainage bag was routinely cleaned, disinfected, monitored, or replaced according to accepted standards of practice. An LPN confirmed there were no physician orders addressing when the drainage bag should be changed or instructions for cleaning or disinfecting it. An RN case manager stated the drainage bag should have been changed weekly, but no orders related to changing, cleaning, or disinfecting were present. The DON stated the facility expected clear physician orders and nursing instructions for catheter care, cleaning, monitoring, and replacement schedules, and confirmed the facility could not provide evidence that such orders or guidance were in place for the resident’s condom catheter drainage bag care.
Failure to Preserve Dignity by Placing a Brief on a Continent Resident
Penalty
Summary
The facility failed to provide services in a dignified manner for 1 resident who was cognitively intact and had diagnoses including renal insufficiency, DM, and hypertension. The resident’s MDS identified him as continent of bowel and bladder and needing staff assistance with ADLs including bed mobility, transfers, and toileting. A bowel and bladder assessment also identified the resident as continent, and the care plan stated he was aware of the need to void or defecate and would request to use the toilet as needed. During interview, the resident stated staff put diapers on him even though he was not incontinent and said it made him feel like a baby. During observation, a NA placed a brief on the resident, and the resident showed the surveyor the brief and stated it had just been put on him a few minutes earlier. The NA verified she placed a brief on the resident that morning even though he was not incontinent and said she was unsure why she did so. RN-A confirmed the resident was continent and stated staff put a brief on him out of habit. The DON stated staff should not place a brief on residents who are continent and that it was important to maintain the resident’s dignity.
Failure to Provide Restorative Ambulation and Address Decline in Mobility
Penalty
Summary
The facility failed to provide restorative ambulation services and failed to respond to a decline in ambulation status for one resident who had mild cognitive impairment, dementia, hypertension, diabetes, weakness, and chronic pain. The resident’s care plan and restorative documentation directed daily ambulation with a front wheeled walker and staff assistance of one, and the resident was also identified as having limited physical mobility and being at risk for falls due to weakness, chronic pain, and an unsteadied gait and balance. However, the nursing rehab point-of-care record repeatedly documented ambulation as “not applicable,” with only one entry showing the resident ambulated for 15 minutes and one entry showing refusal. The resident stated she could no longer walk and that staff needed to help her get into bed and her wheelchair. Staff interviews confirmed the ambulation task was not being completed. A nursing assistant stated aides were responsible for ambulation but were not completing it, and another nursing assistant stated ambulation was supposed to be done but was not done very often; that staff documented it as not applicable when it did not get done; and that the resident had not walked at all for several weeks and was using a sit-to-stand lift with assist of two for all transfers. An RN stated the task just did not get done and that no plan had been created to fix it. The DON stated the resident’s condition had changed and a therapy evaluation should have been requested, and also stated the care plan needed revision because the resident would not be transferred with an assist of one. The resident’s medical record lacked an assessment for ADL decline, including any revision to the ambulation care plan.
Failure to Complete and Document Restorative ROM and Splinting
Penalty
Summary
The facility failed to ensure range of motion (ROM) was completed in accordance with therapy recommendations to maintain mobility for one resident with mild cognitive impairment who was dependent on staff for all care areas and had diagnoses including diabetes, hemiplegia, and hemiparesis. The resident’s care plan identified limited physical mobility, fall risk, weakness, contractures, and limited ROM, and included restorative nursing interventions for bilateral lower extremity passive ROM to active ROM, passive hamstring and heel cord stretches, PROM to both hands, and splint use for the hands. The resident’s restorative documentation from 4/20/26 through 5/19/26 showed the hand splints were worn 41 times and marked not applicable 20 times out of 90 opportunities, but the documentation did not identify refusals to wear the splints. The leg stretches were completed 3 times out of 30 opportunities, and the documentation did not identify why the stretches were not performed or whether they were refused. The resident’s untitled nurse aide care sheet also identified a restorative program and encouragement to participate in the Well Fit program. During interviews, a nursing assistant stated staff were supposed to encourage participation in the Well Fit program and complete PROM and AROM, but it did not get done very often and was often documented as not applicable because it was not offered. An RN stated nursing assistants were responsible for restorative programs but they did not get done, and no plan had been created to fix the issue. The DON stated staff should have offered the tasks and documented refusals, but believed staff may have stopped offering after repeated refusals; the DON also stated the restorative program needed to be updated and that staff were documenting tasks as not applicable, which she was unaware of.
Dirty can opener and contaminated dry storage bins
Penalty
Summary
The facility failed to keep 1 of 1 commercial can opener clean and sanitary and failed to store dry goods removed from original packaging in a manner that reduced the risk of cross-contamination. During an initial tour with the Director of Culinary Services (DCS), four white plastic bins in the food preparation area were observed on the floor and labeled for flour, white sugar, rice, and powdered sugar. The flour bin was about one-third full and had a black scoop partially covered with flour, including the handle. The bin labeled white sugar had yellowish-tan dry matter on the right lateral wall, and the front wall had red dry matter measuring 6-7 cm in diameter. The rims around the lids of all four bins were dirty with dark dust-like particles, and the DCS verified these findings and stated the scoop should not be left inside the bins and needed to be clean inside and out. The attached [NAME] brand can opener was also observed with its blade halfway covered with dry, red-colored matter. On a later kitchen tour, the can opener blade still had dry red matter, which had been pushed upward by 0.2 cm, and a small light amber particle was noted below it. The cook stated he had used the can opener that morning to open a can of cream of corn used for lunch. The DCS verified the dry matter on the can opener and stated it should be washed every time it was used to prevent cross contamination. Facility policy stated dry storage areas would be maintained to keep food safe and free of infestation or contamination, and the sample cleaning schedule stated can openers should be clean after each use.
Dignified Medication Administration Not Maintained
Penalty
Summary
The facility failed to provide a dignified experience for 1 of 2 residents, R20, during medication administration. R20’s records showed severely impaired cognition, inattention, disorganized thinking, verbal behaviors toward others, and diagnoses including severe dementia with psychotic disturbance, visual hallucinations, generalized anxiety disorder, PTSD, and delusional disorder. Her care plan identified mood, behavior, and sleep alterations related to Alzheimer’s disease, dementia, generalized anxiety disorder, paranoia, public outbursts, and accusations that people were throwing medications down her throat, and it directed staff to redirect and reapproach when she was resistive or combative, use a calm approach, provide reassurance, and offer comfort items. During observation, RN-A brought medications to R20 in the dining room and attempted to pour them from a small plastic cup into her mouth. When R20 removed one medication, Divalproex, and threw it on the floor, RN-A attempted again to pour the remaining medications into her mouth while R20 moved her head back and forth and tried to pull away. RN-A then raised her voice, stated the resident’s name, told her she needed to take her medications, pulled her chair back from the table, picked up the Divalproex from the floor, placed it in a separate cup, and asked why she would not take her medications. R20 responded that it was because the nurse was not being nice. RN-A then left with the remaining refused medications and stated R20 would take them later and that she always had a behavior when taking her morning medications.
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