Interfaith Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Carlton, Minnesota.
- Location
- 811 Third Street, Carlton, Minnesota 55718
- CMS Provider Number
- 245024
- Inspections on file
- 23
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Interfaith Care Center during CMS and state inspections, most recent first.
A resident with CVA history and atrial fibrillation was receiving apixaban, but the care plan and provider orders did not include monitoring for bruising or bleeding. Staff interviews confirmed that anticoagulant monitoring should include watching for bleeding and bruising, and the facility’s medication monitoring policy identified enhanced monitoring for anticoagulants.
A resident with severe cognitive impairment and a care plan directing staff to respect her treatment decisions was administered morphine after refusing it, with staff physically restraining her to do so. Multiple staff witnessed and reported the incident, which involved a nurse instructing a nursing assistant to hold the resident's hands down while medication was given, in violation of the resident's rights and facility policy prohibiting restraints.
A resident with severe cognitive impairment and multiple diagnoses was physically restrained by staff and administered morphine against her wishes, despite her care plan directing staff to respect her treatment decisions and provide reassurance if she refused care. Staff interviews and documentation confirmed that a nurse instructed another staff member to hold the resident's hands while medication was given, and witnesses reported the nurse dismissed the resident's distress. The incident was not in accordance with facility policy, and the nurse involved was no longer employed at the facility.
A resident with severe cognitive impairment and a high risk for exploitation was physically restrained and given medication against her wishes by staff, with the incident witnessed and documented by other staff members. Despite the resident's distress and the facility's policy requiring immediate reporting of suspected abuse, the DON did not report the incident to the state agency, citing a lack of malicious intent.
A resident with severe cognitive impairment was physically restrained and given morphine against her wishes by an RN, despite her care plan directing staff to respect her treatment decisions. Staff reported the incident, but the DON did not interview the involved nurse or follow up with the resident or other staff, and no immediate protective actions were taken. The facility's abuse prevention policy requiring immediate investigation and protection was not followed.
A facility failed to assess smoking safety for a resident who was a current smoker with a history of depression, chronic pain, and syncope. Despite being informed of the non-smoking policy, the resident was witnessed smoking on and off the property without a proper assessment of their smoking safety. Interviews with staff confirmed the lack of smoking assessments, posing a risk to the resident's safety.
Anticoagulant Monitoring Not Included in Care Plan or Orders
Penalty
Summary
The facility failed to implement appropriate monitoring for a resident receiving an anticoagulant medication. The resident had an admission MDS identifying intact cognition, cerebral infarction due to unspecified occlusion or stenosis of the right carotid arteries, atrial fibrillation, and use of an anticoagulant medication. The resident’s CAA worksheet noted that daily use of anticoagulants increases the risk for bruising and skin injury and can extend wound healing time, but the care plan dated 1/29/26 only included a focus on stroke and directions to give medications as ordered and monitor/document side effects and effectiveness. The care plan did not identify monitoring for bruising or bleeding, and the provider orders also did not reflect such monitoring. An order dated 4/19/26 prescribed apixaban 5 mg twice daily for atrial fibrillation. During interviews, an LPN stated anticoagulant monitoring should include watching for bleeding and ensuring related labs were done, but could not find that monitoring on the TAR. An RN stated residents on coumadin, Eliquis, or any anticoagulant should have bleeding and bruising monitoring, and the DON stated residents on anticoagulants needed monitoring because bleeding may not stop and the provider would need to be updated. The facility policy on Medication Monitoring stated high-risk medication monitoring for anticoagulants includes enhanced monitoring such as INR monitoring.
Failure to Honor Resident's Right to Refuse Medication and Avoid Restraint
Penalty
Summary
A resident with diagnoses including malignant neoplasm of the breast, hypertension, dementia, depression, and anxiety, and who was assessed as having severe cognitive impairment, was administered morphine despite expressing refusal. The resident's care plan identified her as high risk for exploitation and directed staff to allow her to make decisions about her treatment as able, including respecting refusals of medication. On the day of the incident, the resident was observed calling out and refusing medication, verbally expressing 'no' and physically turning her head away. Despite this, a registered nurse instructed a nursing assistant to hold the resident's hands down while morphine was administered orally against her will. Multiple staff members reported the incident, noting the resident's distress and the nurse's actions, including laughing at the resident's complaints. The facility's policy prohibits the use of restraints and emphasizes the use of the least restrictive interventions. Documentation and interviews confirmed that the resident's right to refuse medication was not honored, and physical restraint was used to administer medication, contrary to both the resident's care plan and facility policy.
Failure to Ensure Resident's Right to Refuse Restraints and Medication
Penalty
Summary
A deficiency occurred when staff failed to ensure a resident's right to remain free from physical restraints, as required by facility policy and federal regulations. The incident involved a resident with severe cognitive impairment, a history of dementia, depression, anxiety, and malignant neoplasm of the breast. The resident's care plan specifically directed staff to allow her to make decisions about her treatment as able, and to provide reassurance and return later if she refused care or medication. Despite these directives, staff held the resident's hands and administered morphine against her expressed wishes. Multiple staff interviews and employee statements confirmed that the resident was yelling for help and expressing distress, stating she was 'sick of being tied down.' A registered nurse instructed another staff member to hold the resident's hands down while morphine was administered orally, despite the resident's verbal refusal and physical resistance. Witnesses reported that the nurse laughed at the resident's distress and dismissed her complaints, further contributing to the resident's sense of fear and lack of safety. Documentation and interviews indicated that the resident rarely required as-needed pain medication and was generally able to communicate her needs. Staff acknowledged that restraining a resident to administer medication was inappropriate and not in accordance with facility policy. The nurse involved was an agency staff member and was no longer working at the facility at the time of the investigation.
Failure to Report Alleged Abuse Involving Physical Restraint and Forced Medication
Penalty
Summary
The facility failed to report an allegation of abuse to the state agency after a resident with severe cognitive impairment, multiple diagnoses including dementia, and a care plan indicating high risk for exploitation was physically restrained and administered medication against her wishes. Documentation and staff interviews revealed that the resident, who had a history of calling out and refusing medications, was held down by staff at the direction of an RN while being given pain medication, despite her verbal refusal and attempts to turn her head away. The resident expressed distress, stating she was tired of being tied down, and staff observed the RN laughing at her while she was upset. The Director of Nursing (DON) was informed of the incident by staff who were upset about the manner in which the medication was administered. The DON acknowledged that holding a resident's hands down to administer medication constituted a restraint but did not report the incident to the state agency, as the on-call nurse believed there was no malicious intent. This inaction was contrary to the facility's Abuse Prevention Plan, which requires immediate reporting of suspected abuse or maltreatment.
Failure to Investigate and Protect After Alleged Abuse and Improper Medication Administration
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with severe cognitive impairment, who was physically restrained and administered morphine against her wishes. The resident, who had diagnoses including malignant neoplasm of the breast, hypertension, dementia, depression, and anxiety, was identified as being at high risk for exploitation and unable to accurately report abuse. Staff statements indicated that the resident was yelling for help and refused medication, but a registered nurse instructed staff to hold the resident's hands down and administered the medication despite her resistance. The nurse also made dismissive remarks when the resident expressed distress about being restrained. Despite being informed of the incident and staff concerns, the DON did not interview the nurse involved or follow up with the resident or other staff present during the incident. The nurse continued to work the following day, and no immediate protective measures were implemented for the resident or others. The facility's abuse prevention policy required immediate protection and investigation, including suspension of the alleged perpetrator and assessment of the alleged victim, but these steps were not followed after the incident.
Failure to Assess Smoking Safety for Resident
Penalty
Summary
The facility failed to assess smoking safety for a resident who was a current smoker. The resident, who was cognitively intact, had a history of depression, chronic pain, difficulty walking, and syncope. Despite being identified as a current everyday smoker upon admission, the resident's care plan did not include any information about their smoking status or safe smoking interventions. The medical record lacked any smoking assessments prior to a specific date, and the facility's smoking policy was reviewed with the resident upon admission. However, the resident was witnessed smoking in the facility parking lot and across the street after outings, indicating a lack of proper assessment and supervision. Interviews with facility staff, including a nursing assistant, a registered nurse, and the director of nursing, confirmed that the facility was non-smoking and that residents were informed of this policy upon admission. Despite this, the resident was not assessed for smoking safety upon admission or after being observed smoking. The director of nursing acknowledged that smoking assessments were not being completed for residents identified as smokers, which posed a risk to resident safety. The facility recognized the importance of smoking assessments to ensure resident safety, even when residents smoked off the property.
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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