Victory Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Minneapolis, Minnesota.
- Location
- 512 49th Avenue North, Minneapolis, Minnesota 55430
- CMS Provider Number
- 245544
- Inspections on file
- 50
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Victory Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident was hospitalized after a safety incident and later discharged from the facility without the emergency family contacts being notified. Documentation did not show any communication with the family about the resident's hospitalization or discharge, and interviews confirmed that family members were unaware of these events until they visited the facility in person.
A resident was transferred to the ED due to safety concerns, but neither the resident nor their family received a written notice of transfer or information about the facility's bed hold policy. The EMR lacked documentation of these notifications, and staff interviews confirmed that only verbal notice was typically provided, with no written policy in place or uploaded to the record.
A resident with asthma and intact cognition was found keeping and using an albuterol inhaler at their bedside without staff knowledge or a documented assessment for self-administration. Although there was a provider order for the inhaler, no assessment or care plan interventions for self-administration were completed, contrary to facility policy. Staff confirmed that proper procedures for assessing and documenting self-administration were not followed.
A resident with severe cognitive impairment and psychiatric diagnoses was found without access to a call light, contrary to her care plan and facility policy. The call light was discovered on the floor under the bed, and staff interviews confirmed that call lights should be within reach to allow residents to request assistance.
A resident with severe cognitive impairment and multiple psychiatric diagnoses received ECT twice weekly, but staff failed to monitor and document temperature and IV site condition as required by care plan and discharge instructions. Nursing staff and the DON confirmed that only behaviors and certain symptoms were monitored, omitting temperature and IV site checks after ECT sessions, despite provider and policy expectations.
An allegation of abuse involving two residents in a physical altercation, resulting in injury, was not reported to the State Agency within the required two-hour timeframe. Staff interviews revealed confusion about reporting procedures, and the incident was only reported several days later, contrary to facility policy.
A medication cart was left unlocked and unattended for about 30 minutes in a hallway, during which time multiple staff and residents passed by, and a resident touched items on the cart. The responsible LPN confirmed the cart should have been locked, and facility leadership reiterated that locking medication carts is required by policy.
A resident with severe cognitive and physical impairments was left to struggle with meals without assistance, violating dignity standards. Observations showed the resident attempting to eat independently in bed and later being assisted while seated alone in the dining room by untrained staff. Facility policies on meal assistance and dignity were not adhered to.
A resident with severe cognitive and physical impairments, including a history of stroke and right-sided hemiplegia, was found to have an inaccessible call light on multiple occasions. Despite the care plan's instructions to keep the call light within reach to prevent falls, it was repeatedly observed in a drawer out of reach. The resident struggled to eat without assistance, and staff confirmed the call light should have been accessible, indicating a failure to meet the resident's needs.
A resident with multiple medical conditions, including diabetes, repeatedly requested the exclusion of orange juice from their breakfast tray, but the facility failed to honor this preference. Despite the facility's policy to assess and implement individual food preferences, the resident continued to receive orange juice, contrary to their requests. The Food Service Director acknowledged that residents should receive their preferred choices within their dietary orders.
A resident with severe cognitive and physical impairments was not provided with the appropriate therapeutic diet and meal supervision, nor was the resident transferred safely according to their care plan. Observations showed the resident was left unsupervised during meals with inappropriate food items and was transferred using a pivot method instead of the required Hoyer lift. Staff interviews confirmed misunderstandings of the resident's needs, and facility policies on meal assistance and safe transfers were not followed.
A resident with a complex medical history experienced significant unplanned weight loss due to the facility's failure to provide necessary meal assistance and prescribed nutritional supplements. Observations showed the resident often left meals untouched without encouragement or setup assistance. Staff interviews revealed a lack of awareness and documentation regarding the resident's nutritional supplement, and the resident's weight was not adequately monitored, violating the facility's weight assessment policy.
A facility failed to include an end date for a PRN psychotropic medication order for a resident with moderate cognitive impairment and receiving hospice care. The resident was prescribed Lorazepam for anxiety without a stop date, contrary to facility policy requiring a 14-day limit unless justified by the provider. Interviews with staff confirmed the oversight and highlighted the need for documented rationale and specified duration for extended use.
A resident with severe cognitive and physical impairments, including dysphagia, was left to eat without assistance and later helped by an untrained social services director. The facility's policy did not ensure only qualified staff assisted residents with meals, leading to a deficiency in care.
The facility failed to properly sanitize dishware due to inadequate water temperatures in their low-temperature chemical sanitizing dishwasher. Despite using chlorine test strips to measure sanitizer concentration, the water temperature consistently fell below the required 120 F. Staff confusion and lack of proper training contributed to the deficiency, and the issue was not addressed by maintenance or reported to the service company.
The facility failed to coordinate appointments for two residents, leading to missed medical visits. One resident with glioblastoma missed neurosurgery and oncology appointments due to poor communication, while another with eye issues experienced delays in specialist care. Additionally, a resident with liver failure was not monitored for edema despite significant weight gain, and medications were improperly administered through a feeding tube without proper orders.
The facility failed to provide individualized non-pharmacological interventions in the care plans for two residents on psychotropic medications. One resident, with cognitive impairments and mental health diagnoses, expressed distress without receiving tailored interventions. Staff interviews revealed a lack of awareness of specific interventions, and the DON confirmed the absence of individualized care plans, contrary to facility policy.
The facility failed to provide individualized non-pharmacological interventions for two residents on psychotropic medications. One resident, with cognitive impairment and a history of depression and anxiety, expressed distress without specific interventions in place. Staff addressed the resident's distress uniformly, lacking individualized strategies. Another resident, dependent on staff for daily activities and on antipsychotic medication, also lacked non-pharmacological interventions in their care plan, contrary to facility policy.
A facility failed to ensure proper hand hygiene and Enhanced Barrier Precautions (EBP) for residents requiring such measures. A nursing assistant did not change gloves or perform hand hygiene after catheter care, and an LPN did not use gown and gloves for a resident with a dialysis line, mistakenly believing EBP was for the roommate. Interviews confirmed the facility's expectations for infection control, highlighting lapses in adherence to policies.
Failure to Notify Family of Resident Hospitalization and Discharge
Penalty
Summary
The facility failed to communicate with a resident's emergency family contacts regarding significant events, including the resident's hospitalization and subsequent discharge. The resident was admitted to the facility and later sent to the emergency department due to safety concerns after being found unredirectable and walking towards traffic. Documentation in the electronic medical record did not show any evidence that the facility informed the resident's family about the safety incident, the hospitalization, or the discharge from the facility. Interviews with the resident's emergency contacts revealed that they were not notified of the resident's hospitalization or discharge. One family member only learned of the hospitalization after visiting the facility and being told by staff that the resident had been taken to the hospital by paramedics. The family also reported difficulty obtaining information from the facility and was not informed about the resident's discharge until they visited in person. The facility administrator and social worker confirmed that there was no documentation of communication with the family regarding these events, and the facility was unable to provide a discharge policy.
Failure to Provide Written Transfer Notice and Bed Hold Policy Upon Hospitalization
Penalty
Summary
The facility failed to provide a written notice of transfer and information regarding the bed hold policy to a resident and/or their family when the resident was hospitalized. The resident's electronic medical record showed an admission and subsequent discharge after being sent to the emergency department due to being unredirectable and walking towards traffic, which posed a safety concern. Documentation in the EMR did not show that the resident or their family received a written notice of transfer or information about the facility's bed hold policy at the time of hospitalization. During interviews, the resident's emergency contact confirmed not being informed or receiving any written notice or bed hold information, and the facility social worker stated that only verbal notice was typically given and documented in a progress note, with no awareness of a specific written notice policy. The facility administrator confirmed that a written notice and bed hold policy should have been uploaded to the EMR but were not present for this resident. No bed hold or written notice of transfer policy was provided for review.
Failure to Assess and Document Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a self-administration of medications assessment was completed for a resident who was observed with medication at their bedside. The resident, who had intact cognition and diagnoses including morbid obesity and asthma, was found to have an albuterol inhaler at their bedside, which they used as needed without notifying staff. The resident's most recent self-administration assessment indicated they did not wish to self-administer medications, and their care plan did not address self-administration. However, the resident kept and used the inhaler independently several times a week. Staff interviews confirmed that when a medication is found in a resident's room, it should be removed and an assessment should be completed to determine if self-administration is safe, followed by obtaining a provider order if appropriate. In this case, although there was a provider order for the inhaler, there was no order or documented assessment for self-administration, nor was it addressed in the care plan. The facility's policy requires an interdisciplinary assessment and documentation in the medical record and care plan if self-administration is deemed safe and appropriate, which was not followed in this instance.
Failure to Ensure Call Light Accessibility for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to accommodate the needs of a resident with severe cognitive impairment and multiple psychiatric diagnoses by not ensuring the resident's call light was within reach, as required by the care plan and facility policy. During observation, the resident was found lying in bed without a call button accessible, and stated she did not have one, relying instead on waving or calling out to staff for assistance. Further inspection revealed the call light was on the floor under the bed, and both an LPN and a nursing assistant confirmed that staff are expected to ensure call lights are within reach before leaving a resident's room. The director of nursing also affirmed the importance of call light accessibility for resident communication. Facility policy directs staff to make call lights accessible from the bed, toilet, shower, and floor.
Failure to Monitor Temperature and IV Site After ECT
Penalty
Summary
The facility failed to monitor temperature and intravenous (IV) access site for a resident following electroconvulsive therapy (ECT) as required by the resident's care plan and discharge instructions. The resident, who had severe cognitive impairment and diagnoses including schizoaffective disorder, bipolar type, and catatonic schizophrenia, received ECT twice weekly. The care plan and ECT discharge instructions specified monitoring for extreme headache, nausea, vomiting, confusion, temperature greater than 100.5°F, and signs of IV site complications such as redness, swelling, drainage, or pain lasting more than 24 hours. However, the physician orders transcribed into the resident's record did not include monitoring for temperature or IV site complications after ECT, and the treatment administration record (TAR) and nurse's notes lacked documentation of these assessments on multiple occasions when ECT was administered. Interviews with nursing staff and the director of nursing confirmed that special monitoring was documented in the TAR according to provider orders, which in this case did not include temperature or IV site monitoring after ECT. The medical director stated that nurses should follow patient instructions for monitoring after ECT, including checking temperature and IV site. Despite this, the resident's temperature was only checked once during the relevant period, and there was no documentation of IV site monitoring after any of the ECT sessions. The facility's policy required the interdisciplinary team to document improvements or worsening in behavior, mood, and function, but the required monitoring for post-ECT complications was not completed or documented as ordered.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure that an allegation of potential abuse involving two residents engaged in a physical altercation was reported to the State Agency (SA) immediately, but no later than two hours as required. The incident involved a verbal altercation escalating to one resident allegedly striking another in the face, resulting in injuries including a dislocated jaw and chest wall contusion. Documentation showed that both residents were cognitively intact, with one having a recent history of verbal behaviors. The incident occurred late in the evening, but the report to the SA was not submitted until several days later. Interviews with staff revealed confusion and lack of awareness regarding the correct abuse reporting procedures. One LPN reported the incident only to the DON, not to the administrator or the SA, while another LPN was unaware of how to report to the SA and referenced unclear instructions. The DON and administrator both acknowledged that abuse allegations should be reported to the SA within two hours, but this protocol was not followed due to staff not being properly informed and the incident occurring over a weekend. The facility's policy required immediate reporting of alleged abuse, but this was not adhered to in this case.
Unattended and Unlocked Medication Cart
Penalty
Summary
A medication cart located outside the dining room on the [NAME] Hall was observed to be unlocked and unattended for approximately 30 minutes. During this period, thirteen staff members and eleven residents passed by the cart, and one resident touched items on top of it. The responsible LPN confirmed she had left the cart unattended and acknowledged that it should have been locked to prevent unauthorized access. Additional interviews with another LPN, the director of nursing, and the administrator confirmed that facility policy and standard practice require medication carts to be locked when unattended. The facility's Medication Labeling and Storage policy also specifies that medications and biologicals must be stored in locked compartments accessible only to authorized personnel.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident with severe cognitive impairment and physical limitations due to a stroke. The resident required substantial assistance with meals and was on a mechanically altered diet. During an observation, the resident was left in bed with a breakfast tray and struggled to eat independently, using his left hand to eat sausage and attempting to open a water bottle with his teeth. No staff were present to assist, and a nursing assistant entered the room briefly but did not acknowledge or assist the resident. Later, the resident was observed in the dining room, seated alone in a wheelchair, while the social services director stood next to him to assist with lunch. The director admitted to not having received feeding assistance training and was unaware that standing while assisting was undignified. Interviews with staff, including a licensed practical nurse and the director of nursing, confirmed that staff should sit next to residents when assisting with meals to ensure a dignified experience. The facility's policies emphasized the importance of checking food consistency and positioning a chair next to the resident for assistance, which were not followed in this instance.
Inaccessible Call Light for Resident with Severe Impairments
Penalty
Summary
The facility failed to ensure that a call light was accessible for a resident with severe cognitive impairment and physical limitations. The resident, who had a history of stroke, aphasia, and right-sided hemiplegia, required substantial assistance with most activities of daily living. The care plan for the resident indicated that the call light should be within reach to prevent falls. However, during multiple observations, the call light was found inside the top drawer of the nightstand, out of the resident's reach. On several occasions, the resident was observed in bed with meals in front of him, struggling to eat without assistance and attempting to open a water bottle with his teeth. No staff were present to assist, and the call light remained inaccessible. Interviews with a nursing assistant and the director of nursing confirmed that the call light should have been within reach, as per the facility's policy on answering call lights. The deficiency was identified through these observations and interviews, highlighting a failure to accommodate the resident's needs and preferences as outlined in their care plan.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor and implement the food preferences of a resident, identified as R24, who was reviewed for choices. R24 has multiple medical diagnoses, including multiple sclerosis, type II diabetes mellitus with hyperglycemia, major depressive disorder, and adjustment disorder. The resident's clinical physician orders specified a diabetic diet with regular texture and thin liquids consistency. However, during an observation, it was noted that the breakfast tray provided to R24 included items that the resident had specifically requested to be excluded, such as orange juice. Despite R24's repeated requests to exclude orange juice from the breakfast tray, it continued to be provided every morning. The Food Service Director confirmed that the dietary aide is responsible for verifying the resident menu slip and stated that residents should receive their preferred choices as long as they align with the ordered diet. The facility's policy on resident food preferences, dated July 2017, indicated that individual food preferences should be assessed upon admission and staff should interview residents to determine their preferences. However, this policy was not effectively implemented in R24's case, leading to the deficiency.
Failure to Provide Adequate Supervision and Safe Transfers
Penalty
Summary
The facility failed to provide appropriate therapeutic diet and meal supervision for a resident with severe cognitive impairment and physical disabilities. The resident, who had a history of stroke, aphasia, dysphagia, and right-sided hemiplegia, required a mechanically altered diet and substantial assistance with eating. Observations revealed that the resident was left unsupervised during meals, struggling to manage food items that were not appropriately prepared for his dietary needs, such as whole waffles and an unpeeled hard-boiled egg. Staff failed to check for food pocketing, and the resident was observed attempting to open a water bottle with his teeth, indicating a lack of adequate supervision. The facility also failed to ensure safe transfer methods for the resident, who was assessed to require a Hoyer lift for transfers due to his physical limitations. Despite this, staff were observed using a pivot transfer method without the necessary equipment, contrary to the resident's care plan and therapy recommendations. Interviews with staff revealed a misunderstanding of the resident's transfer needs, with some staff incorrectly believing that the resident did not require a lift or transfer belt. Interviews with various staff members, including the director of rehabilitation services, licensed practical nurse, and director of nursing, confirmed that the resident should have been supervised during meals and transferred using a Hoyer lift. The facility's policies on assisting impaired residents with meals and safe lifting and moving of residents were not followed, contributing to the deficiencies observed. The lack of adherence to these policies resulted in inadequate care and supervision for the resident, as evidenced by the observations and staff interviews.
Failure to Prevent Weight Loss in Resident
Penalty
Summary
The facility failed to comprehensively assess and implement interventions to prevent weight loss for a resident with significant unplanned weight loss. The resident, who had a complex medical history including vascular dementia, dysphagia, and Crohn's disease, was not provided with the necessary assistance for meals and did not receive a prescribed nutritional supplement. Observations revealed that the resident was often left in bed with meals untouched, and there was no encouragement or setup assistance provided by the staff. The resident's care plan indicated a need for setup assistance with meals, yet this was not consistently provided. The dietary notes highlighted the resident's potential nutritional problems and the need for dietary supplements, but these were not administered as ordered. Interviews with staff revealed a lack of awareness and documentation regarding the resident's nutritional supplement, and the resident's weight was not adequately monitored or flagged for significant weight loss. The facility's policy on weight assessment and intervention was not followed, as the resident's weights were not recorded in the weight chart, and there was no evaluation or intervention noted in the care plan. The failure to implement the prescribed nutritional interventions and monitor the resident's weight contributed to the resident's continued weight loss, highlighting a deficiency in the facility's care practices.
Failure to Include End Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication order for a resident included an end date. The resident, who had moderate cognitive impairment and was diagnosed with lung cancer and depression, was receiving hospice care and had been prescribed Lorazepam for anxiety. The provider's order for Lorazepam, dated 12/13/24, specified a dosage of 0.25 milliliters every 4 hours as needed but did not include a stop date. This oversight was confirmed during an interview with an LPN, who acknowledged that the order should have been limited to 14 days unless otherwise justified by the provider. Further interviews with the Director of Nursing (DON) and the consultant pharmacist revealed that the facility's policy required all PRN psychotropic medications to have a stop date of 14 days unless extended with provider justification. The DON noted that hospice providers typically wrote orders for 90 days, but this was not reflected in the resident's order. The consultant pharmacist reiterated that even if the medication was not an antipsychotic, an end date was still necessary. The facility's policy on antipsychotic medication use, revised in 7/2022, also directed that PRN psychotropic medications needed beyond 14 days must include a documented rationale and specified duration in the order.
Unqualified Staff Assisting Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that residents with difficulty swallowing were assisted with meals only by qualified individuals. A resident with severe cognitive impairment, upper and lower extremity impairment, and a history of stroke, aphasia, dysphagia, and right-sided hemiplegia required substantial assistance with meals and a mechanically altered diet. Despite these needs, the resident was observed struggling to eat independently without staff assistance, and later, was assisted by a social services director who was not trained as a feeding assistant. The facility's policy did not specify that only qualified staff should assist residents with meals, and the social services director admitted to helping the resident without having received any feeding assistance training. Interviews with staff, including a licensed practical nurse and the director of nursing, confirmed that only trained individuals should assist residents with meals, especially those on a dysphagia diet. The speech therapist also emphasized the need for supervision and assistance for the resident during meals, highlighting the facility's failure to adhere to these requirements.
Inadequate Dishware Sanitization Due to Low Water Temperature
Penalty
Summary
The facility failed to ensure proper sanitization of dishware used for meal preparation and resident service due to inadequate wash and rinse temperatures in their low-temperature chemical sanitizing commercial dishwasher. The dietary manager and dietary aide demonstrated the use of the dishwasher, which was identified as an Ecolab ES2000, and used chlorine test strips to measure the chemical sanitizer concentration. The concentration was found to be within the acceptable range of 100-200 ppm, but the water temperature was consistently below the required 120 F, reaching only between 112 F and 118 F during various observations. The dietary aide expressed confusion about the water temperature requirements and incorrectly recorded the temperature as 150 F on the log, despite the actual readings being lower. The dietary manager acknowledged the issue but stated that the dishwasher used chemicals to sanitize, implying that the water temperature was not a concern. However, the dishwasher service representative later confirmed that the machine required a minimum water temperature of 120 F during the wash and rinse cycles for proper sanitization. The facility's maintenance staff and administrator were unaware of the inadequate temperature issue, and the service company had not been contacted to address it. The administrator assumed the chemical sanitizer was effective based on the test strip results, but the lack of a user manual and proper training for staff contributed to the deficiency. The facility's policies lacked specific information on water temperature requirements during chemical sanitation, further compounding the issue.
Deficiencies in Appointment Coordination, Edema Monitoring, and Medication Administration
Penalty
Summary
The facility failed to ensure proper coordination of scheduled and follow-up appointments for two residents who required services from outside medical providers. One resident with cognitive impairment and diagnoses of glioblastoma and schizophrenia missed multiple neurosurgery and oncology appointments due to a lack of communication and coordination between the facility and the outside providers. The Health Unit Coordinator (HUC) was responsible for coordinating these appointments but was unaware of the missed appointments until later. Another resident, who had a history of retinal detachment and cataract surgery, experienced a delay in scheduling a follow-up eye specialist appointment, which was attributed to a communication gap within the facility. The facility also failed to monitor a resident with liver failure and ascites for edema. Despite the resident's significant weight gain over a short period, there was no indication in the medical records that the resident required monitoring for edema. The resident expressed concerns about swelling, but the staff did not document or implement interventions to address the edema. The registered nurse acknowledged the lack of monitoring and attributed the weight gain to the resident's dietary habits, despite the resident's history of edema-related issues. Additionally, the facility did not adhere to standard practices for administering medications through a feeding tube for a resident with multiple diagnoses, including stroke and hypertension. The registered nurse administered a mixture of crushed and liquid medications without an order to cocktail them, which is against the facility's expectations. The Director of Nursing stated that each medication should be administered separately with a flush of water in between, and an order should be present if medications are to be combined.
Lack of Individualized Care Plans for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to include individualized non-pharmacological interventions in the comprehensive care plan for two residents, leading to a deficiency in managing unnecessary medications. One resident, who was moderately cognitively impaired and diagnosed with dementia, depression, and a psychotic disorder, was on routine antidepressant and antipsychotic medications. Despite the resident's significant change in condition, the care plan lacked specific interventions tailored to their mental health needs, such as non-pharmacological approaches to manage behavior. Observations and interviews revealed that the resident expressed distress and negative emotions, yet staff interventions were not individualized. During an observation, the resident was heard crying and expressing negative feelings, but staff only placed them in bed without addressing the underlying issues. Interviews with various staff members, including a registered nurse, a trained medication aide, and a licensed practical nurse, indicated a lack of awareness and implementation of resident-specific interventions for mental health concerns. The Director of Nursing confirmed that the care plan did not contain individualized interventions for the resident's depression and anxiety. The facility's policy on antipsychotic medication use emphasized the need for behavioral interventions to be attempted and included in the care plan, which was not adhered to in this case. This oversight highlights the importance of tailoring care plans to meet the specific needs of residents, particularly those with mental health issues.
Lack of Individualized Non-Pharmacological Interventions for Residents
Penalty
Summary
The facility failed to identify individualized non-pharmacological interventions for two residents, R1 and R27, who were reviewed for unnecessary medications. R1, who was moderately cognitively impaired with diagnoses of dementia, depression, and psychotic disorder, was on multiple psychotropic medications. Despite having a care plan that included various interventions for anxiety and mood problems, there was no evidence of non-pharmacological, resident-specific interventions. Observations revealed that R1 expressed distress and negative emotions, yet staff did not have specific interventions to address these behaviors, relying instead on general approaches. Interviews with staff, including a registered nurse, a trained medication aide, a licensed practical nurse, and a nursing assistant, indicated a lack of awareness and implementation of resident-specific interventions for R1. The staff addressed R1's distress in a uniform manner, without individualized strategies, and the director of nursing confirmed the absence of specific interventions in R1's care plan. This lack of individualized care planning was evident despite R1's history of suicidal ideation and anxiety, highlighting a deficiency in the facility's approach to managing R1's mental health needs. Similarly, R27, who had moderately impaired cognition and was dependent on staff for all activities of daily living, was receiving antipsychotic medication for mood disorder. R27's care plan included monitoring for side effects and effectiveness of medications but lacked non-pharmacological, resident-specific interventions. The facility's policy on antipsychotic medication use emphasized the need for behavioral interventions to be attempted and included in the care plan, yet this was not reflected in R27's care plan, indicating a systemic issue in the facility's management of psychotropic medication use and care planning.
Infection Control Deficiencies in Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed during personal and catheter care for a resident with moderately impaired cognition and an indwelling catheter. During an observation, a nursing assistant did not change gloves or perform hand hygiene after completing catheter and perineal care before touching various surfaces and items in the resident's room. The nursing assistant acknowledged the lapse in protocol during an interview, despite being aware of the correct procedures. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for a resident with a dialysis port, as required by the facility's policy. An LPN was observed assisting the resident with various tasks, including removing a shirt and transferring the resident, without donning the necessary gown and gloves. The LPN mistakenly believed the EBP sign on the door was for the resident's roommate, not the resident with the dialysis line. Interviews with the infection preventionist, RN, and interim Director of Nursing confirmed the expectations for hand hygiene and EBP usage. The facility's policy required gown and gloves for high-contact care activities for residents with indwelling medical devices. The interim DON acknowledged that the resident with the dialysis line should have been on EBP, indicating a lapse in adherence to the facility's infection control policies.
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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