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Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Minnesota Veterans Home - Silver Bay during CMS and state inspections, most recent first.
Medications Left at Bedside Without Self-Administration Approval: A resident with renal insufficiency, anxiety, and depression had a SAM assessment indicating the resident did not want to self-administer and was no longer able to do so, yet nicotine throat lozenges were observed on the bedside table with no staff present. The resident’s orders and care plan lacked bedside-medication/self-administration instructions, and staff interviews confirmed a SAM assessment and order were needed before medications could be left at bedside.
Medication Administered Not Per Provider Order: A cognitively intact resident with renal insufficiency, anxiety, and depression had an order for nicotine throat lozenge 4 mg, one lozenge PO every hour PRN, but staff were observed giving two lozenges at a time. The TMA confirmed the order was for one lozenge and stated staff had been giving the resident two lozenges, while the RN and DON stated medications should only be administered as ordered.
A resident with stroke, hemiplegia, and dysphagia was care planned for a regular diet with thin liquids, bite-size food, and assist of one with meals, but staff did not follow those interventions. Observations showed meatloaf and coffee cake were served without being cut up, and no staff were present to assist while the resident ate. The cook said food should have been cut into bite-size pieces, while an NA said she was not aware she was assigned to assist with all meals.
A resident who was cognitively intact and dependent for toileting received incontinent care in which an NA cleaned the peri area, then continued with the same contaminated gloves while placing a clean brief, dressing the resident, and handling supplies. The clean brief contacted the soiled brief during the process, and interviews with the NA, RN, IP, and DON confirmed gloves should be changed when moving from dirty to clean parts of care; the facility hand hygiene policy addressed hand hygiene before and after resident cares.
Failure to timely report alleged physical abuse: A resident reported that an NA grabbed the resident’s left hand in a not gentle manner, causing pain and possible bruising. The incident was documented in the facility report and progress note, but the allegation was not reported to the SA within the required 2-hour timeframe; staff interviews indicated the report was not made until the next morning after the day nurse was informed.
A resident with multiple health conditions received another resident's medications due to a nurse preparing multiple residents' medications simultaneously. This error led to the resident experiencing bradycardia and hypotension, requiring emergency department care. The nurse involved was removed from medication duties and re-educated on proper practices.
Medications Left at Bedside Without Self-Administration Approval
Penalty
Summary
The facility failed to ensure medications were not left at a resident bedside when the resident was assessed as unable to self-administer medications. The deficiency involved one resident whose quarterly MDS indicated cognitive intactness and whose diagnoses included renal insufficiency, anxiety, and depression. The resident’s Provider Order Summary Report lacked orders to keep medications at bedside, and the care plan lacked information related to self-administration of medications. The resident’s Self Administration of Medications &/or Treatments assessment dated 3/20/26 indicated the resident did not want to self-administer medications and was no longer able to self-administer. Despite this, during observations on 4/13/26 and 4/14/26, two white pills identified by the resident as nicotine throat lozenges were observed on the bedside table with no staff present in the room. During interviews, a TMA stated she very rarely leaves medications at bedside and was unsure what needed to be in place for medications to remain there when staff were not present, and confirmed the resident had nicotine throat lozenges left at bedside. An RN stated a SAM assessment and order needed to be in place before medications could be left at bedside so the resident could self-administer. The DON stated the SAM assessment needed to indicate the resident wanted to self-administer and was able to self-administer before medications could be left at bedside, and that staff were expected to confirm the appropriate information before leaving medications at bedside. Facility policy stated a comprehensive assessment would be completed to ensure the resident wanted to and had the capability to self-administer medications and keep medications at bedside.
Medication Administered Not Per Provider Order
Penalty
Summary
The facility failed to follow provider orders and administer medications as ordered for one resident who was cognitively intact and had diagnoses including renal insufficiency, anxiety, and depression. The resident had an order for nicotine throat lozenge 4 mg, one lozenge by mouth every hour as needed. During observation, two white pills identified by the resident as nicotine throat lozenges were seen on the bedside table, and later the resident requested two nicotine throat lozenges. At that time, a TMA entered the room with a medication cup containing two nicotine throat lozenges and gave both to the resident. The TMA stated medications should only be administered according to the provider's order, confirmed she gave two lozenges even though the order was for one at a time every hour as needed, and stated staff had been giving the resident two lozenges at a time. The RN and DON stated medications should only be administered as ordered by the provider, and the facility policy indicated staff would ensure the correct medication and correct dose were only administered based on the provider order.
Failure to Follow Meal Assistance and Bite-Size Food Care Plan
Penalty
Summary
The facility failed to implement and follow interventions for a resident who required assistance with meals. The resident’s quarterly MDS identified him as cognitively intact, with diagnoses including stroke, hemiplegia, and dysphagia. His care plan identified a regular diet with thin liquids, with all foods needing to be cut into bite-size pieces and assistance of one with meals. The East Dining Assistance Roster also identified him as an assist of one for meals, and care conference notes documented that he agreed to a bite-size diet and assist of one with meals, with the care plan updated. During observation, the resident was served mashed potatoes with gravy and a piece of meatloaf, and he began feeding himself while the meatloaf was not cut into bite-size pieces and no staff were present to assist him. On another observation, he received a piece of coffee cake that was not cut up and again ate without staff around to assist. The cook stated the food should have been cut into bite-size pieces and that cooks were responsible for cutting food, while the nursing assistant stated she was not aware she was an assist for all meals and did not stay with him while he ate. The RN stated the resident had agreed to bite-sized food and assistance with meals, and the DON stated staff were expected to follow the care plan and provide care based on the care plan.
Infection Control Lapse During Incontinent Care
Penalty
Summary
Provide and implement an infection prevention and control program was not completed during incontinent care for one cognitively intact resident with diagnoses of stroke and cancer who was frequently incontinent of bladder and always incontinent of bowel and required maximum assistance with toileting. The resident’s care plan directed staff to check and change the brief and provide perineal care. During observation, a nurse assistant entered the room, washed hands, donned gloves, and gathered supplies to change the resident’s saturated brief and clean the peri area. While performing the care, the nurse assistant cleaned the front peri area and buttock region, then rolled the dirty brief and the clean brief together so the clean brief came into contact with the soiled brief. The disposable chuck under the resident had wet areas where the peri-area would be located. With the same contaminated gloves still on, the nurse assistant placed the new brief, secured it, transferred the resident to a wheelchair, dressed him, and returned peri care supplies to the closet while touching several items. Interviews with the NA, RN, IP, and DON confirmed gloves should be changed when moving from dirty to clean parts of care, and the facility policy stated staff would perform hand hygiene before and after resident cares.
Failure to Timely Report Alleged Physical Abuse
Penalty
Summary
The facility failed to report an allegation of staff-on-resident physical abuse within two hours to the State Agency for one resident, R54. On 6/6/25 at about 8:00 p.m., R54 reported that a nurse assistant grabbed the resident’s left hand in a not gentle manner, causing pain and possible new bruising. A facility incident report later documented that R54 was handled roughly by a staff member and came into contact with the left hand, causing injury and pain. In a progress note entered at 10:39 p.m. on 6/6/25, staff documented that the resident complained the nurse assistant had grabbed the left hand roughly and caused pain and injury. During interview, RN-C stated R54 reported the concern to her around 8:00 p.m. and she could not remember whether she notified anyone right away. The infection preventionist stated the complaint was not reported to the State Agency until about 10:15 a.m. on 6/7/25, after the day nurse informed her. Facility policy required all allegations of abuse, neglect, exploitation, or mistreatment to be reported no later than two hours after the allegation was made.
Medication Error Leads to Resident Harm
Penalty
Summary
The facility failed to ensure medications were administered to the correct resident, resulting in a significant medication error for one resident. This resident, who had intact cognition and multiple diagnoses including chronic kidney disease, hypertension, and heart failure, was mistakenly given another resident's medications. The error occurred when a registered nurse (RN) prepared medications for multiple residents simultaneously and inadvertently administered the wrong set to the resident in question. Following the administration of incorrect medications, the resident developed symptoms of bradycardia and hypotension, including severe dizziness, which necessitated emergency department evaluation and treatment. The resident's blood pressure and pulse were significantly low, prompting the nurse practitioner to order immediate hospital transfer. The resident's hospital records confirmed the administration of incorrect medications and detailed the resulting symptoms, including lightheadedness and weakness. The RN involved in the incident admitted to setting up medications for three residents at once, which led to the error. Upon realizing the mistake, the RN reported it to the charge nurse, who then took over the resident's care. The RN was subsequently removed from medication administration duties and later re-educated on proper medication administration practices. The facility's consultant pharmacist and nurse practitioner both emphasized the importance of preparing medications for one resident at a time to prevent such errors.
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Nursing homes near Silver Bay
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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Waterview Shores Llc | 26.5 mi | — | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.