Mn Veterans Home Minneapolis
Inspection history, citations, penalties and survey trends for this long-term care facility in Minneapolis, Minnesota.
- Location
- 5101 Minnehaha Avenue South, Minneapolis, Minnesota 55417
- CMS Provider Number
- 245620
- Inspections on file
- 27
- Latest survey
- September 22, 2025
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at Mn Veterans Home Minneapolis during CMS and state inspections, most recent first.
A resident with a documented DNR order became unresponsive after a fall, and an LPN initiated CPR after misreading the POLST form, mistakenly interpreting the code status as full code. Staff interviews revealed inconsistent methods for verifying code status, and the facility's protocol requiring verification before CPR was not followed.
Surveyors found that the facility did not have a policy or procedure in place for facility closure. When asked, the facility could not provide documentation of such a policy, and the assistant administrator confirmed its absence. This issue had the potential to impact all residents.
A resident with multiple comorbidities received 100 mg of liquid morphine instead of the prescribed 5 mg due to an LPN's failure to follow medication administration protocols, including dose verification with another nurse. The error was discovered after the resident's condition deteriorated, and the incident resulted in the resident's death.
Staff serving a special meal to residents on the 3rd floor did not wear hairnets while preparing and plating food, despite using gloves and standing over the food items. Facility leadership and policy confirmed that hairnets were expected to be worn to prevent contamination, and this lapse had the potential to affect 32 residents.
A resident reported a missing shirt, alleging it was taken by a staff member, but the facility failed to document the grievance in the official log, did not provide timely or adequate follow-up with the resident, and did not offer the required property loss or Tort claim forms. Staff interviews confirmed that investigation results were not communicated to the resident and necessary documentation was incomplete.
The facility did not provide appropriate skin protection interventions for a resident on anticoagulant therapy who experienced ongoing bruising, nor did it follow physician orders for ankle compression sleeves for another resident with edema. Staff failed to offer or document the use of protective sleeves, and care plans lacked specific interventions for both conditions, despite clear documentation and resident reports of unmet needs.
A resident with a history of hearing loss reported difficulty hearing in crowded environments and expressed interest in obtaining hearing aids. Despite discussing this need with a provider and declining in-house audiology services in favor of an external evaluation, there was no documented follow-up or action taken by staff to assist the resident in obtaining hearing aids. The facility's policy referenced audiology services but did not outline a process for helping residents access them.
The facility did not ensure that a resident with severe cognitive and physical impairments consistently attended scheduled therapy gym sessions, with most absences lacking documented reasons. Additionally, occupational therapy recommendations for another resident at risk for hand contractures were not care planned or implemented, and staff were unaware of required interventions. These failures resulted in residents not receiving appropriate care to maintain or improve range of motion.
A resident with multiple chronic conditions, including COPD and respiratory failure, repeatedly declined or removed prescribed supplemental oxygen, yet the facility failed to analyze these refusals or update the care plan accordingly. Staff documented and observed frequent non-use of oxygen, but provider notes lacked this information, and the care plan did not address the ongoing issue, despite facility policy requiring explanations for treatments not administered.
A resident who was not enrolled in a self-administration medication program received prescription ointment applications from nursing assistants, despite facility policy requiring only licensed staff to administer medications. Staff interviews confirmed that nursing assistants regularly applied the medicated cream, and documentation inaccurately reflected unsupervised self-administration. The facility did not have trained medication aides, and the practice was not in line with established policy.
Staff did not consistently use gowns and gloves or perform proper hand hygiene during high-contact care for two residents with wounds, including one with a history of MRSA. One resident with a stage two pressure ulcer was not assigned enhanced barrier precautions, and staff did not follow facility protocols for infection prevention and control.
The facility failed to assess a resident with severe cognitive impairment and COPD for the ability to self-administer nebulizer medication. The resident was observed using the nebulizer without supervision, leading to an incident where the resident called for help and was left unattended for several minutes. Staff interviews revealed inconsistencies in monitoring and assessment practices.
A resident with Parkinson's, diabetes, and depression, recently admitted to hospice, did not have their food preferences adequately assessed or honored. Despite expressing a dislike for chicken and a preference for pasta, the resident repeatedly received meals they could not eat due to dental issues and personal dislikes. Staff interviews revealed inconsistencies in documenting and communicating meal preferences, leading to the resident's frustration and inadequate nutrition.
A resident with intact cognition reported a missing electric toothbrush to staff, who failed to take timely action to resolve the issue. The nurse did not complete the required form, and the social worker was unaware of the missing item, resulting in no follow-up or resolution.
The facility failed to consistently implement assessed and care-planned interventions for skin monitoring for a resident with non-pressure skin impairments. Despite being scheduled for weekly skin checks, these were not consistently performed or documented, and the resident expressed concerns about a recurring rash that was not being adequately monitored.
The facility failed to assess and develop a bowel continence program for a resident with Parkinson's disease, diabetes, and depression. Despite being cognitively intact and dependent on toileting, the resident was not offered alternatives like a bedpan and had to defecate in his brief, causing discomfort. Staff were unaware of the resident's concerns, and the care plan lacked individualized interventions.
A resident with heart failure and depression did not receive a timely throat culture due to a labeling error and lack of follow-up. Staff interviews revealed communication lapses and ineffective use of the facility's lab tracking process.
The facility failed to ensure recommended pneumococcal vaccinations were offered and provided to a resident and did not document education regarding influenza vaccination benefits and side effects for five residents. Interviews revealed uncertainty about whether the required education was being provided and documented as expected.
Failure to Honor DNR Order Due to Misinterpretation of POLST
Penalty
Summary
The facility failed to honor a resident's Physician Orders for Life-Sustaining Treatment (POLST) indicating Do Not Resuscitate (DNR), Do Not Intubate, and Allow Natural Death. After the resident, who had Alzheimer's disease and had been a DNR since admission, became unresponsive following a fall, an LPN initiated cardiopulmonary resuscitation (CPR) despite the DNR order. The LPN misread the POLST document, as her finger covered the DNR check mark, leading her to interpret the code status as full code and begin CPR. The ambulance staff continued lifesaving efforts and transported the resident to the hospital, where further resuscitation was attempted. Interviews with facility staff revealed inconsistent practices for verifying code status, with some staff relying on the POLST in the chart, others on the electronic medical record, and some on chart spine color coding. The LPN involved stated she had received training on reading POLST forms but still misinterpreted the document in the emergency. The resident's family member, who was the appointed healthcare representative, confirmed the resident's DNR status and expressed concern upon learning that CPR had been performed. The facility's policy required verification of code status before initiating CPR, but this protocol was not followed in this incident.
Removal Plan
- Health unit coordinator, nurse manager, and registered nurses check all resident charts to ensure POLST matches the electronic medical record banner and the chart's spine color.
- Staff are educated on emergency protocols.
- Staff are educated on where to check code status.
- Two people verify the POLST.
- Audits are completed with staff and training is verified.
- Code drills are completed where staff read the POLST and correctly identify if a full code or DNR.
- Ongoing audit schedule evaluates staff knowledge regarding the POLST and where to find the code status.
Lack of Facility Closure Policy and Procedure
Penalty
Summary
The facility failed to develop and maintain a policy and procedure for facility closure, as required. During the survey, when requested, the facility was unable to provide documentation of a facility closure policy. In an interview, the assistant administrator confirmed that the facility was unable to locate such a policy. This deficiency had the potential to affect all residents residing in the building.
Significant Medication Error: Morphine Overdose Due to Dose Miscalculation
Penalty
Summary
A significant medication error occurred when a licensed practical nurse (LPN) administered 5 ml (100 mg) of liquid morphine to a resident, instead of the prescribed 5 mg dose. The resident, who had a history of cerebral vascular accident (stroke), diabetes, dementia, and atrial fibrillation, was dependent on staff for most activities of daily living and was experiencing respiratory distress. The nurse practitioner (NP) had ordered morphine 5 mg every hour as needed for shortness of breath, with the medication available in a concentration of 20 mg/ml. The LPN failed to correctly calculate and administer the ordered dose, resulting in the resident receiving 20 times the intended amount of morphine. The facility's medication administration protocol required two nurses to verify the amount of liquid narcotic to be given, especially when a dosage calculation was necessary. However, the LPN did not verify the dose with another nurse as required by facility policy. The error was discovered when the nurse manager noticed that the medication order had not been confirmed in the electronic chart and upon review, found that the LPN had documented administering 5 ml instead of the correct 0.25 ml (5 mg) dose. The nurse manager initially believed the resident had received 20 mg, but later calculations revealed the actual dose was 100 mg. Following the administration of the incorrect dose, the resident's condition deteriorated, with declining oxygen saturation and increased agitation. The NP was notified and gave orders to hold further morphine and monitor the resident. The family was informed of the medication error and chose not to transfer the resident to the hospital. The resident's condition continued to worsen, and he passed away a few hours after receiving the overdose. The facility's investigation identified the failure to follow the five rights of medication administration and the lack of required double-checking of the dose as the root causes of the error.
Removal Plan
- The facility completed a thorough investigation identifying the root cause that LPN-A did not follow the medication right or right dose and did not verify the dose with another nurse.
- LPN-A was placed on a leave pending the investigation.
- All nursing staff were educated on the medication order transcription process, order confirmation process, ensuring orders are confirmed and appear on the electronic medication record prior to administration, double noting of liquid narcotics to ensure correct dosing on order and in the narcotic book.
- IDT meeting was held to discuss the use of liquid narcotics in the facility vs. sublingual morphine to propose the change to the pharmacy for emergency medication kit use.
Failure to Ensure Staff Wore Hairnets During Meal Service
Penalty
Summary
Staff failed to serve food in a sanitary manner by not wearing hairnets while preparing and plating meals for residents on the 3rd floor of building 19. During observation, two staff members were seen using gloves but did not have their hair properly contained with hairnets as they stood over and handled food items, including fried chicken, mashed potatoes, gravy, coleslaw, and buns. The food was brought into the facility for a special meal and was not served by dietary staff or from the kitchenette. Interviews with the assistant director of nursing, culinary director, director of dietary services, and director of nursing confirmed that the expectation was for staff to wear hairnets when plating food to prevent contamination. The facility's policy on dress, appearance, and hygiene also indicated that hair must be tied back and/or covered when required for sanitation reasons. The failure to follow these procedures had the potential to affect 32 residents residing on the 3rd floor of building 19.
Failure to Timely Address and Document Resident Grievance Regarding Missing Property
Penalty
Summary
A cognitively intact resident reported a missing black long sleeve shirt, alleging it was stolen by a staff member while the resident's back was turned. The resident immediately reported the incident to the nurse manager, but the initial progress notes did not document the missing item until a late entry was made several days later. The facility's missing item tracker did record the missing item, but the grievance was not entered into the facility's official grievance complaint log. Following the report, the nurse manager and assistant director of nursing interviewed both the resident and the accused staff member, reviewed security camera footage, and filed a report with the Minnesota Department of Health. However, there was no documented follow-up with the resident regarding the outcome of the investigation, and the missing item tracker only contained demographic information without investigation results. The resident stated that the nurse manager did not return to discuss the results or clarify whether the investigation was ongoing, and the resident was not offered the opportunity to file a property loss or Tort claim for reimbursement. Interviews with facility staff confirmed that the required property damage/loss form was not completed for the resident, and no follow-up progress notes documented further investigation or communication with the resident after the initial entries. The facility's policy required that a claim report and demand form be provided upon request when a claimant suffered property loss, but there was no evidence this was offered or completed for the resident in question.
Failure to Provide Skin Protection and Follow Compression Sleeve Orders
Penalty
Summary
The facility failed to conduct accurate and ongoing assessments for bruising and did not implement appropriate skin protection interventions for a resident on anticoagulant therapy. The resident, who was cognitively intact and independent with mobility, had a history of easy bruising related to apixaban use. Despite documentation of ongoing bruising and the resident expressing interest in trying skin protection sleeves, staff did not offer or provide these interventions. Interviews with nursing staff confirmed that no skin protectant or derma sleeves were care planned or provided, and the resident had not previously been offered these items, contrary to facility expectations for residents on anticoagulants. Additionally, the facility failed to follow physician orders for the application of ankle compression sleeves for another resident with edema. The resident, who had no cognitive impairment and was being treated with diuretics for edema, had an active order for bilateral ankle compression sleeves to be applied in the morning and removed at bedtime. Observations and interviews revealed that the resident was not wearing the prescribed compression sleeves on multiple occasions, and staff confirmed that the task was not included in the care plan or Kardex. Documentation in the treatment administration record indicated the sleeves were applied and removed, but direct observation and resident statements contradicted this. Both deficiencies were further compounded by the lack of specific interventions in the care plans for the identified conditions and the absence of relevant facility policies for anticoagulant use/monitoring and edema management. The facility's skin management program referenced preventive interventions but did not address the specific needs of residents with anticoagulant therapy or edema, and requested policies were not provided.
Failure to Follow Up on Resident's Request for Hearing Aids
Penalty
Summary
A deficiency occurred when the facility failed to follow up and implement treatment for a resident who reported hearing loss and expressed interest in obtaining hearing aids. The resident, who had intact cognition and was noted to have adequate hearing on the quarterly MDS, reported to the provider during admission that he had an audiogram indicating some hearing loss, particularly in crowded environments, and was interested in further evaluation for hearing aids. The medical record showed that the resident declined in-house audiology services but wanted an audiology evaluation to pursue hearing aids. However, there was no documentation of any follow-up or action taken to address the resident's request for hearing aids. During interviews, the resident confirmed that he had discussed his need for hearing aids with a doctor but had not received any updates or the devices themselves. The nurse manager was unaware of the resident's request and, after reviewing the medical record and consulting with staff, found no evidence that the request had been addressed. The facility's policy identified audiology as a service that could be provided and charged to residents' personal funds but did not specify the process for assisting residents in obtaining such services.
Failure to Ensure Consistent Range of Motion Interventions and Therapy Attendance
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and significant physical limitations consistently attended scheduled therapy gym sessions as ordered. Documentation showed that the resident was marked as 'not available' for 11 out of 13 scheduled sessions, with no documented reasons for most absences. Staff interviews revealed inconsistent communication and documentation practices regarding the resident's attendance and reasons for missed sessions, despite care plan interventions specifying the need for staff to escort the resident to the gym and provide transportation. Additionally, the facility did not implement or care plan occupational therapy recommendations for another resident assessed as at risk for bilateral hand contractures and impaired skin due to clenching fists. Occupational therapy notes indicated the resident would benefit from holding an object during the day and participating in active assisted and passive range of motion programs. However, these interventions were not included in the resident's care plan or communicated to nursing staff, and observations confirmed the resident was not provided with recommended objects to hold or enrolled in a hand range of motion program. Both deficiencies were identified through a combination of record review, staff interviews, and direct observation. The lack of documentation and follow-through on therapy recommendations and scheduled interventions resulted in residents not receiving appropriate care to maintain or improve their range of motion and mobility, as required by their care plans and therapy orders.
Failure to Address and Care Plan Resident's Repeated Oxygen Therapy Refusals
Penalty
Summary
The facility failed to analyze and care plan a resident's repeated declinations to wear supplemental oxygen as ordered. The resident, who had diagnoses including COPD, respiratory failure, heart failure, and other chronic conditions, was ordered to receive continuous supplemental oxygen to maintain oxygen saturation at or above 90%. Despite this, documentation and observations revealed that the resident frequently did not wear the prescribed oxygen, with multiple instances of refusal or removal of the nasal cannula noted in progress notes and during direct observation. The care plan for the resident included interventions such as assisting with oxygen tank changes, setting the oxygen flow rate, and monitoring oxygen saturation, but it did not address the resident's refusals or any alternative strategies for non-compliance. Staff documented several occasions where the resident either refused or removed the oxygen, sometimes after education on risks and benefits, but there was no evidence that these refusals were analyzed or incorporated into the care plan. Provider notes also lacked documentation of these refusals, and there was no indication that the care plan was updated to reflect the ongoing issue. Interviews with staff confirmed that the resident often removed the nasal cannula, sometimes unintentionally, and that staff would encourage use and notify the provider. However, there was inconsistency in staff awareness and documentation of the refusals, and the assistant director of nursing stated that ongoing issues should be care planned. The facility's policy required explanations for medications or treatments not administered, but this was not consistently followed for the resident's oxygen therapy refusals.
Unlicensed Staff Applied Medicated Ointment Contrary to Policy
Penalty
Summary
The facility failed to ensure that staff were competent and authorized to apply medicated ointment for a resident who was not participating in a self-administration medication program. The resident, who was cognitively intact and had diabetes, had an active order for Triamcinolone Acetonide ointment to be applied to itchy, dry skin. The care plan did not identify a self-administration program, and documentation indicated the resident did not wish to self-administer medications. Despite this, the treatment administration record showed daily documentation of unsupervised self-administration, while observations and interviews confirmed that nursing assistants, rather than licensed staff, were applying the medicated ointment to the resident. Multiple staff interviews revealed that nursing assistants regularly applied the prescription ointment, with one assistant describing the process and confirming the ointment was kept in the resident's room. The nurse educator and assistant director of nursing both confirmed that there were no trained medication aides on campus and that only licensed staff were permitted to administer medications per facility policy. However, a licensed practical nurse described a practice where nursing assistants could apply medicated creams if the resident confirmed their understanding, after which the LPN would document the administration. This practice was not supported by facility policy, which specified that only certified or licensed staff should administer medications.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene for Residents with Wounds
Penalty
Summary
The facility failed to ensure proper implementation of enhanced barrier precautions (EBP) and hand hygiene protocols for residents with wounds. For one resident with a history of MRSA in a right foot wound, staff did not consistently wear gowns and gloves during high-contact care activities such as peri-care, transferring, and toileting, despite signage indicating the need for these precautions. Observations revealed that staff wore only gloves, omitted gowns, and did not perform hand hygiene between glove changes while providing care. Interviews with staff confirmed a lack of adherence to EBP and hand hygiene expectations during these activities. Additionally, the facility did not assign EBP to another resident with a stage two pressure ulcer on the left big toe. This resident's care plan and physician orders did not indicate the need for EBP, and there was no signage or PPE cart outside the room. Staff interviews revealed that EBP was not being used for this resident, and the care plan lacked documentation of an MDRO, which was cited as a criterion for EBP by the assistant director of nursing. However, the facility's own infection prevention program indicated that residents with wounds, such as pressure ulcers, should be identified for EBP. The facility's policies directed staff to use gowns and gloves during high-contact care for residents on EBP and to perform hand hygiene between glove changes. Despite these policies, observations and staff interviews demonstrated that these protocols were not consistently followed, resulting in deficiencies related to infection prevention and control for residents with wounds.
Failure to Assess and Monitor Resident for Self-Administration of Nebulizer Medication
Penalty
Summary
The facility failed to assess a resident (R49) for the ability to self-administer medications via a nebulizer. R49 had severe cognitive impairment and diagnoses of COPD and dementia. Despite these conditions, R49 was observed using a nebulizer without staff supervision. During the observation, R49 was seen holding the nebulizer mask away from his face, calling for help, and coughing. Staff were not present in the room or hallway, and it took several minutes before a nursing assistant entered the room to assist R49. The nebulizer machine was left running unattended until a registered nurse turned it off later. Interviews with staff revealed that R49 was not assessed for the ability to self-administer medications and that staff usually checked on R49 after 15 minutes, which was not done on the observed night. The director of nursing confirmed that staff were expected to attend all medication administrations unless the resident was assessed as safe to self-administer medications, which was not the case for R49. The facility's policy on self-administration of medications required that residents be determined capable and safe to self-administer by the interdisciplinary team. However, R49's self-administration assessment indicated that R49 did not request to self-administer medications. Despite this, R49 was left alone with the nebulizer, leading to the observed incident. Staff interviews highlighted inconsistencies in monitoring and assessing R49's ability to self-administer medications, contributing to the deficiency. The facility's failure to properly assess and monitor R49 during nebulizer treatments resulted in a lapse in care and adherence to their own policies.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to comprehensively assess a resident's food preferences and ensure meal choices were provided. The resident, who was cognitively intact and had diagnoses of Parkinson's disease, diabetes, and depression, was on a liberalized diet due to recent admission to hospice. Despite the resident's care plan indicating they were independent in making food choices, the care plan lacked specific food preferences. The resident expressed frustration with the meals provided, stating they disliked chicken and preferred pasta, but these preferences were not reflected in the meals served. An observation confirmed that the resident's meal tray did not match the meal ticket, and the resident was unable to eat the food provided due to dental issues and personal dislikes. Interviews with staff revealed inconsistencies in the process of gathering and updating resident meal preferences. Nursing assistants and licensed practical nurses indicated that residents attended group meetings to make menu selections, but if a resident was unable to attend, the dietician would review the menu for them. However, the resident's meal preferences were not adequately communicated or documented, leading to repeated instances of the resident receiving meals they could not eat. The dietician acknowledged the resident's dental issues and food dislikes but was unaware of the specific problems with meal tickets not matching the served trays. The dining service supervisor and dietician both stated that meal tickets should be completed in advance and could be changed if necessary, but there was a lack of coordination and communication between the dietary staff and nursing staff. The dietician admitted that the resident's dislikes were not reviewed during the last nutrition assessment, and special requests were not always accommodated by the culinary team. The facility's policy regarding resident choices was requested but not provided, indicating a potential gap in the facility's procedures for ensuring resident meal preferences are honored.
Failure to Act on Resident's Grievance of Missing Item
Penalty
Summary
The facility failed to ensure a voiced grievance of a missing electric toothbrush was acted upon timely for a resident with intact cognition and no delusional behavior. The resident reported the missing item to a nursing assistant and a nurse, who did not take immediate action to resolve the issue. The resident expressed frustration over the lack of follow-up, and the nurse admitted to not completing the required form to report the missing item, hoping it would be found in the resident's room instead. The resident's medical record lacked evidence of any actions taken to locate the missing electric toothbrush or report it to the management team for resolution. The social worker, who would have been responsible for addressing the issue, was unaware of the missing item due to the nurse's failure to complete and route the necessary form. The facility's policy required the first staff person notified of a missing item to complete a form and route it for further action, which was not done in this case.
Failure to Consistently Implement Skin Monitoring Interventions
Penalty
Summary
The facility failed to ensure that assessed and care-planned interventions for skin monitoring were consistently implemented for a resident (R246) with non-pressure skin impairments. R246, who had intact cognition and required substantial assistance with bathing, was at risk for pressure ulcer development and had current moisture-associated skin damage (MASD). Despite being scheduled for weekly skin checks on bath days, the facility did not consistently perform these checks. The Treatment Administration Record (TAR) indicated that the last completed Weekly Skin Check was on 2/22/24, with no checks or refusals documented for 2/29/24 and 3/14/24. R246 expressed concerns about a recurring rash on his legs, which staff were not applying lotion to daily, and there was no clear documentation of monitoring by nurses. Interviews with registered nurses (RN-B and RN-A) revealed that the facility's protocol required weekly skin checks to be documented in the medical record, but these checks were not consistently completed. RN-B acknowledged the lack of documentation and was unsure where refusals should be recorded. RN-A confirmed the absence of documentation for the required skin checks and noted that the facility had identified this issue but had delayed staff education due to the survey. The facility's Resident Assessment - Care Plan policy emphasized the importance of implementing care plans to assist residents in attaining the highest practicable level of functionality and wellness, which was not adhered to in this case.
Failure to Develop and Implement Bowel Continence Program
Penalty
Summary
The facility failed to comprehensively assess and develop a program to maintain bowel continence for a resident (R146) who was cognitively intact and had diagnoses of Parkinson's disease, diabetes, and depression. Despite being dependent on toileting and always continent of bowel according to the MDS, the resident's care plan and assessments were inconsistent. The resident was admitted to hospice services and required physical assistance with all cares, yet the assessment lacked a 3-day bowel assessment summary. The care plan indicated the resident was incontinent of bowel with frequent continent episodes and required assistance for toileting, but the resident was not offered a bedpan and was unaware of any bowel program options. Interviews with the resident and staff revealed that the resident had to defecate in his brief and was not provided with alternatives such as a bedpan, which was not commonly used in the facility. The resident expressed discomfort with having bowel movements in the brief. Staff interviews indicated a lack of awareness regarding the resident's concerns and the absence of individualized interventions to maintain bowel continence. The Director of Nursing stated that staff were expected to assess continence accurately and revise interventions to reflect individualized needs, including the use of bedpans or commodes, which was not done in this case.
Failure to Obtain Timely Throat Culture for Resident
Penalty
Summary
The facility failed to ensure a provider order for a throat culture was obtained in a timely manner for a resident reviewed for infection. The resident, who was cognitively intact and had diagnoses of heart failure and depression, complained of a sore throat and received a STAT order for a throat culture to test for streptococcal bacteria. The throat culture was obtained but later canceled due to a labeling error, and no new orders were obtained despite the resident's ongoing symptoms and complaints of pain. Interviews with staff revealed a lack of communication and follow-up regarding the pending lab results. The LPN and RN involved were unaware of the canceled test until days later, and the facility's communication process for tracking lab tests was not effectively utilized. The Director of Nursing confirmed that the lab would not notify the facility of unprocessed specimens and emphasized the importance of shift-to-shift reporting and using a red binder to track lab tests. However, the facility's procedure for lab collection was not provided upon request.
Failure to Ensure Proper Vaccination and Education Documentation
Penalty
Summary
The facility failed to ensure recommended pneumococcal vaccinations were offered and/or provided to reduce the risk of severe disease for one resident reviewed for immunizations. Specifically, a resident with intact cognition and multiple diagnoses, including Parkinson's disease, depression, and COPD, had not received or been offered the pneumococcal PCV20 or PPSV23 dose despite having received the PCV13 vaccine several years prior. The resident did not recall any discussion about an updated pneumococcal vaccination and expressed willingness to receive it if available. Additionally, the resident's immunization record did not indicate that education regarding the benefits and potential side effects of the influenza vaccination had been completed, despite the resident having received the influenza vaccine recently. The facility also failed to ensure that the medical records of five residents included documentation that the resident or their representative was provided education regarding the benefits and potential side effects of the influenza immunization. These residents had various medical conditions, including kidney disease, diabetes, heart dysrhythmia, dementia, depression, anxiety, heart failure, Alzheimer's disease, and seizure disorder. Despite receiving the influenza vaccination, their records lacked documentation of the required education. During interviews, the infection preventionist and the Director of Nursing (DON) acknowledged the lack of documentation and expressed uncertainty about whether the education was being provided and documented as expected. The facility's policy indicated that Vaccine Information Statements (VIS) should be provided to residents, their representatives, and families prior to vaccination, but there was no evidence that this was consistently documented in the medical records. The DON emphasized the importance of providing this education to ensure informed decision-making and maintain residents' dignity.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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