Grand Avenue Rest Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Minneapolis, Minnesota.
- Location
- 3956 Grand Avenue S0uth, Minneapolis, Minnesota 55409
- CMS Provider Number
- 24E150
- Inspections on file
- 28
- Latest survey
- November 26, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Grand Avenue Rest Home during CMS and state inspections, most recent first.
A staff member transported soiled linen in an uncovered, unlined basket through common areas where residents were present, contrary to facility policy requiring soiled linen to be covered and lined during transport. Interviews with staff confirmed the expectation to cover and bag soiled linen to prevent contamination.
Several residents with psychiatric diagnoses were administered PRN psychotropic medications without documentation of nonpharmacological interventions being attempted beforehand, despite facility policy and physician orders requiring such actions. Nursing staff and leadership confirmed that these interventions should have been offered and documented, but medical records lacked evidence of compliance.
A resident with intact cognition and psychiatric symptoms repeatedly expressed a desire to move out and pursue alternative living arrangements, but the care plan was not updated to reflect these preferences. Despite multiple documented requests and assessments for discharge, the care plan continued to state the resident wished to remain, and staff interviews confirmed the plan was not current with the resident's goals.
A resident with multiple mental health diagnoses, including PTSD, was identified as high risk and required psychotherapy with an outside provider. The facility did not have a process to obtain or review therapy notes from the external provider, and there was no evidence of collaboration documented in the EMR. Leadership confirmed the lack of a process for ensuring communication with outside therapists, and the resident reported that her specific PTSD triggers were not assessed by the facility.
The facility did not ensure timely action on pharmacist recommendations for two residents prescribed psychotropic medications. One resident's monthly medication review was missing, and for another, a pharmacist's recommendation for a gradual dose reduction was not addressed by the physician, with no documentation of follow-up or rationale. The facility also could not provide a policy on pharmacy recommendations when requested.
A resident was not offered or educated about influenza, pneumococcal, and Covid-19 vaccinations, and there was no documentation in the EMR regarding vaccine education, offer, receipt, or refusal, despite facility policy and CDC guidelines requiring these actions.
Three bedrooms were found to house three residents each, but did not meet the required 80 square feet per resident, with actual space ranging from 65.9 to 79.6 square feet per person. Affected residents reported insufficient space for movement and personal activities, and the administrator confirmed no recent changes to room configurations.
The facility failed to prepare resident care plans with an interdisciplinary team (IDT) that included a nursing aide, attending physician, or resident/resident representative, potentially affecting all 19 residents. Discrepancies were noted in the IDT composition as described by the DON and administrator. The DON admitted that no notes are taken during IDT meetings, which are used to update care plans based on risk management discussions. The facility's IDT policy outlined specific roles for the team.
The facility failed to appoint a registered nurse (RN) as the Director of Nursing (DON), instead having a licensed practical nurse (LPN) in the role since July 2024. The administrator acknowledged the requirement for an RN in the DON position, and the facility lacked a signed job description for the current DON. The deficiency could impact all 19 residents.
The facility did not schedule a registered nurse (RN) for a minimum of eight consecutive hours a day, affecting all 18 residents. Staff schedules from January to March 2024 showed multiple dates without RN coverage. The interim DON confirmed the absence of RN coverage and acknowledged the requirement for RN presence. No staffing policy was provided.
The facility failed to identify and address quality deficiencies, lacking documentation and implementation of corrective actions. The QAPI meeting minutes and reports for the second quarter did not include improvement activities or analysis of adverse events and medical errors. Deficiencies noted in the CASPER report, such as RN coverage and infection control, were not addressed through a Performance Improvement Project (PIP).
The facility failed to handle linen properly, with staff observed carrying both clean and dirty laundry through the kitchen, posing an infection control risk. Additionally, the facility lacked functioning infection surveillance and water management programs, as identified by the newly appointed infection preventionist.
The facility lacked a functioning antibiotic stewardship program, potentially affecting residents needing antibiotics. The infection preventionist, new to the role, identified this issue and intended to rebuild the program. The existing policy was insufficient, lacking protocols and criteria for appropriate antibiotic use.
The facility failed to conduct orthostatic blood pressure monitoring for residents on psychotropic medications, as required for monitoring potential side effects. Four residents with conditions such as schizophrenia and bipolar disorder had orders for such monitoring, but their treatment records lacked documentation over several months. The interim DON acknowledged the absence of active orders and documentation, which is crucial for assessing medication effectiveness and side effects.
A resident with a history of respiratory issues reported symptoms and requested a COVID-19 test, but the facility failed to document the test results or notify the physician. The resident expressed concerns about her health over several days, but staff did not promptly address her requests or document her symptoms, leading to a deficiency in care.
A resident with intact cognition and mental health diagnoses expressed discomfort when staff entered her room without waiting for a response, highlighting a lack of privacy provisions in shared rooms. Observations confirmed the absence of privacy curtains, and staff interviews acknowledged limited privacy options, with the facility considering improvements.
A fire occurred in the smoking room of an LTC facility, but the incident was not reported to the State Agency (SA) or investigated as required by the facility's policies. The interim DON and Administrator were aware of the fire, but no investigation was conducted, and the incident was not reported. A resident attempted to extinguish the fire, and a cook eventually put it out before the fire department arrived.
A resident with schizophrenia and depression did not receive her prescribed sertraline and Serevent Diskus due to the facility's failure to reorder medications timely. The resident experienced nervousness and restlessness, resorting to smoking to calm down. The facility's policy required reordering with less than a five-day supply, but documentation was lacking, and the new process was not effectively implemented.
A resident with COPD and emphysema experienced worsening respiratory symptoms, including shortness of breath and a harsh cough, which were not adequately assessed or documented by the facility. Despite the resident's requests for a COVID test and medical attention, staff did not perform a thorough assessment or comply with her request to call 911, leading her to call an ambulance herself. The facility's failure to recognize and respond to the resident's change in condition resulted in a deficiency.
A resident with a history of smoking-related injuries was observed with a lighter in her room and independently smoking, despite assessments indicating smoking supplies should be stored by staff. Interviews revealed staff were unaware of restrictions on smoking materials, and the DON confirmed the resident should not have had access to a lighter. No safe smoking policy was provided.
A resident did not receive prescribed medications due to an 8% medication error rate at the facility. The LPN could not find the Sertraline HCl medication card, and the Serevent Diskus was expired. Interviews revealed that nurses were responsible for medication orders and refills, but no policy was provided for reordering medications.
The facility did not meet the required minimum square footage per resident in three rooms, affecting nine residents. Rooms 101, 102, and 103 housed three residents each but did not provide the required 80 square feet per resident. Despite this, the rooms were safe and adequately furnished, with no negative impact on the residents observed.
A resident with schizoaffective disorder received a monthly Invega Sustenna injection twice over two days due to documentation and communication errors among staff. The initial dose was missed, and upon discovery, the injection was given on one day and mistakenly repeated the next day. The facility's policy requires verification before administration, but the lack of proper documentation led to the error. The resident was monitored for adverse effects, but none were reported.
The facility failed to maintain accurate accounting of resident trust funds, with discrepancies totaling $7,061.96 and did not provide quarterly statements to 5 of 14 residents. The DON and CFO confirmed the discrepancies and the lack of documentation for statement distribution.
The facility failed to ensure the surety bond contained sufficient funds to protect the total balance of the resident trust fund, which was $24,419.88. The surety bond was only for $20,000, leaving the resident trust funds inadequately insured. The CFO acknowledged this discrepancy during an interview.
A facility failed to update a care plan for a resident with a history of leaving the facility against the leave of absence policy. Despite the resident's repeated absences and noncompliance, the care plan did not reflect these behaviors, and staff acknowledged the need for updates. The oversight was compounded by the fact that the resident's medication administration record indicated she received her scheduled medications despite her absences.
Uncovered Soiled Linen Transported Through Common Areas
Penalty
Summary
A staff member was observed transporting soiled linen in an uncovered basket without a liner or bag through common areas of the facility, including the living room and dining room, where several residents were present. The staff member carried the uncovered linen outside and around the building to the laundry area, confirming during an interview that the basket was not covered or lined during transport. The staff member acknowledged awareness of the expectation to keep soiled linen covered for infection control purposes. Interviews with the infection control preventionist and a nursing assistant confirmed that facility policy requires all soiled linen to be transported in covered containers with a plastic liner, which should be cinched prior to transport. Both staff members reiterated the importance of covering dirty laundry during transport to prevent contamination, in accordance with the facility's updated Linen and Laundry policy. The failure to follow these procedures had the potential to impact all 19 residents in the facility.
Failure to Document Nonpharmacological Interventions Prior to PRN Psychotropic Medication Administration
Penalty
Summary
The facility failed to provide and document appropriate nonpharmacological interventions prior to administering as-needed (PRN) psychotropic medications for three of five residents reviewed for unnecessary medication use. For one resident with diagnoses including anxiety, depression, psychotic disorder, schizophrenia, and PTSD, the medical record showed frequent administration of PRN diazepam over several months. However, there was no documentation of nonpharmacological interventions attempted before medication administration, despite explicit instructions from the consulting pharmacist and physician orders requiring such documentation. Another resident with diagnoses of bipolar disorder with psychotic features, anxiety disorder, and schizoaffective disorder was administered PRN hydroxyzine multiple times. The medication administration records indicated the medication was effective but lacked any documentation of nonpharmacological interventions prior to administration. The resident's care plan listed several nonpharmacological strategies, but progress notes and the electronic medical record did not reflect that these were attempted before giving the medication. Interviews with nursing staff and the assistant director of nursing confirmed the expectation that nonpharmacological interventions should be offered and documented prior to PRN psychotropic medication administration. Review of facility policy also indicated that nurses are required to attempt an intervention before administering PRN psychotropic medication. Despite these requirements, documentation in the medical records did not show that nonpharmacological interventions were attempted or recorded prior to medication administration for the residents reviewed.
Failure to Update Care Plan for Resident's Discharge Preferences
Penalty
Summary
The facility failed to maintain an up-to-date comprehensive care plan for a resident who was reviewed for discharge planning. The resident, who had intact cognition but experienced hallucinations, delusions, and fluctuating disorganized thinking, was independent with all activities of daily living. Despite multiple documented expressions of the desire to move out of the facility and pursue alternative living arrangements, such as assisted living or independent living, the resident's care plan was not updated to reflect these preferences. The care plan continued to state that the resident wished to remain in the facility and only wanted to be asked about discharge plans annually, with the last revision not reflecting the resident's ongoing requests for discharge. Progress notes and interviews with staff confirmed that the resident repeatedly communicated her wish to leave the facility, and assessments for relocation services were initiated. However, the care plan did not document these changes in the resident's goals or preferences. Staff interviews further revealed a lack of awareness or clarity regarding the resident's discharge plans, and both the assistant director of nursing and the social worker acknowledged that the care plan should have been updated to reflect the resident's expressed wishes. The facility's own policy required care plans to be regularly reviewed and updated to reflect changes in condition or preferences, which was not followed in this case.
Failure to Collaborate with External Mental Health Provider for Behavioral Health Services
Penalty
Summary
The facility failed to collaborate with a resident's external mental health provider to ensure necessary behavioral health services were provided. The resident, who was cognitively intact and had diagnoses including major depressive disorder, ADHD, generalized anxiety disorder, panic disorder, and PTSD, was identified as high risk and in need of psychotherapy for PTSD. The care plan specified therapy with an outside provider, but the electronic medical record did not show evidence of collaboration or receipt of therapy notes from the external provider. The director of social services confirmed there was no established process for obtaining therapy notes or collaborating with outside providers, and that such notes were rarely received unless there was a specific issue. Interviews with facility leadership indicated that it was expected for social services to review and upload therapy notes into the resident's EMR, but this was not occurring. The resident reported that while the facility assessed her for PTSD, it did not assess her specific triggers, and she confirmed she attended therapy outside the facility. A request for the facility's behavioral health policy was made but not fulfilled.
Failure to Act on Pharmacist Recommendations and Missing Medication Review
Penalty
Summary
The facility failed to ensure that pharmacist recommendations were acted upon in a timely manner for two residents reviewed for unnecessary medication use. For one resident with diagnoses including hallucinations, delusions, anxiety, and schizophrenia, the facility was unable to provide documentation of a required monthly medication regimen review for June, as confirmed by the administrator. This resident was prescribed multiple antipsychotic and antidepressant medications, and the absence of the June review indicated a lapse in the facility's process for ensuring regular pharmacist oversight. For another resident with intact cognition and psychiatric symptoms, the consulting pharmacist made a recommendation for a gradual dose reduction (GDR) of trazodone, requesting physician review and response. However, the physician did not sign or indicate acceptance or rejection of the recommendation, and there was no documentation of a patient-specific rationale if the recommendation was contraindicated. The assistant director of nursing confirmed that the recommendation was sent to the provider but no response was received, and there was uncertainty about whether any follow-up was attempted. Additionally, the facility was unable to provide a policy on pharmacy recommendations when requested.
Failure to Offer and Document Required Vaccinations
Penalty
Summary
The facility failed to ensure that recommended influenza, pneumococcal, and Covid-19 vaccinations were offered and/or provided in a timely manner, as outlined by CDC guidelines, for one of five residents reviewed for immunizations. Review of the electronic medical record (EMR) for this resident showed no evidence that the resident was educated about, offered, or received or declined the influenza, pneumococcal, and Covid-19 vaccines. During an interview, the infection control preventionist confirmed that the facility's expectation is to offer and document vaccine status for all residents, including documentation of education, what was offered, and whether the vaccine was received or declined. The infection control preventionist also verified that the EMR lacked documentation of refusals and follow-up for the resident's vaccine status. The facility's policy requires that all residents and their legal representatives be offered these vaccines and that the EMR reflect education provided, receipt, or refusal, but this was not followed in the case reviewed.
Failure to Meet Minimum Room Size Requirements for Multiple Residents
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in three multi-resident bedrooms, affecting nine residents. Observations revealed that each of these rooms housed three residents but measured less than the mandated 80 square feet per resident, with actual measurements ranging from 65.9 to 79.6 square feet per person. Interviews with affected residents indicated dissatisfaction with the available space, with one resident stating there was not enough room to move around and another expressing difficulty engaging in personal activities such as crafting due to limited space. The administrator confirmed that no changes or updates had been made to the rooms since the previous survey.
Deficiency in Interdisciplinary Team Care Plan Preparation
Penalty
Summary
The facility failed to prepare resident care plans with an interdisciplinary team (IDT) that included a nursing aide (NA), the attending physician, or a resident/resident representative. This deficiency had the potential to affect all 19 residents in the facility. During interviews, discrepancies were noted in the composition of the IDT as described by the director of nursing (DON) and the administrator. The DON mentioned that the IDT consisted of an RN, the administrator, herself, the social worker, a member from medical records, the infection preventionist (IP) nurse, the minimum data set (MDS) nurse, and a compliance nurse. In contrast, the administrator stated that the IDT included a RN, the DON, a member of the activities department, herself, the social services director, the social services assistant, and a member of the kitchen. Additionally, the DON admitted that they do not take notes during IDT meetings, which are used to update care plans based on risk management discussions. The facility's IDT policy, revised in December, stated that the IDT should include the DON, one other nurse designated by the DON, the social services director and/or assistant, the activity director and/or designee, and other staff members as established by the Administrator.
LPN Serving as Director of Nursing Instead of Required RN
Penalty
Summary
The facility failed to ensure that their Director of Nursing (DON) was a registered nurse (RN), as required. Instead, a licensed practical nurse (LPN) has been serving in the DON role since July 30, 2024. This deficiency was identified during an interview with the facility's administrator, who acknowledged the requirement for an RN in the DON position and confirmed that the current DON is an LPN. The facility did not have a signed job description for the current DON, and the provided job description for the DON role specified that an RN must be hired. Additionally, the DON's educational records did not include any training specific to the DON role. This deficiency had the potential to affect all 19 residents in the facility.
Failure to Schedule RN for Required Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was scheduled for a minimum of eight consecutive hours a day, which had the potential to affect all 18 residents at the facility. A review of the facility staff schedules and staffing hours from January 1, 2024, to March 31, 2024, revealed that there was no RN scheduled on multiple dates, including January 14, 20, 21, 27, 28; February 3, 4, 16, 17, 18, 24; and March 2, 3, 9, 10, 16, 17, 23, 30, and 31. During an interview on August 26, 2024, the interim Director of Nursing (DON) confirmed the absence of RN coverage on these dates. In a follow-up interview on August 28, 2024, the interim DON acknowledged the requirement to have an RN in the building for at least 8 hours a day. The facility was unable to provide a policy regarding staffing when requested.
Facility Fails to Address Quality Deficiencies and Implement Corrective Actions
Penalty
Summary
The facility failed to identify and address quality deficiencies effectively, as evidenced by a lack of documentation and implementation of corrective actions. The facility's Quality Assurance and Performance Improvement (QAPI) meeting minutes for the second quarter lacked documentation of improvement activities, tracking of adverse events, medical errors, and analysis of causes. Additionally, the QAPI reports for the same period included infection control tracking, skin and wounds, and medication errors but did not document any analysis of their causes or preventive actions implemented. This indicates a failure to develop and implement appropriate actions to correct identified deficiencies. The facility had several deficiencies noted in the Certification and Survey Provider Enhanced Reporting (CASPER) system report, including issues with RN coverage, unnecessary psychotropic medications, infection prevention and control, antibiotic stewardship, and emergency preparedness. These deficiencies were not addressed through a Performance Improvement Project (PIP) focusing on high-risk or problem-prone areas, as there was no evidence of such a project being implemented. The social services representative was unaware of any ongoing PIPs, despite the facility's QAPI plan indicating the need for proactive approaches to improve quality of care and life for residents.
Deficiencies in Linen Handling and Infection Control Programs
Penalty
Summary
The facility failed to properly handle linen, which posed an infection control concern. During observations, a nursing assistant was seen carrying dirty resident clothing through the kitchen in a mesh-designed hamper, and later, an uncovered basket of clean linen was also carried through the kitchen. Interviews with the cook aide and the interim director of nursing confirmed that staff were using the kitchen as a passageway for laundry, both clean and dirty, which was against infection control protocols. The interim director of nursing and the infection preventionist both acknowledged that linen should not be transported through the kitchen due to the risk of contamination, but no policy regarding the transportation of linen was provided. Additionally, the facility lacked a functioning infection surveillance program and a water management program. The infection preventionist, who had been in the role for two weeks, identified these deficiencies and expressed the intention to rebuild both programs. The absence of these critical programs indicated a significant gap in the facility's infection prevention and control measures, potentially affecting all residents in the facility.
Lack of Functioning Antibiotic Stewardship Program
Penalty
Summary
The facility failed to have a functioning antibiotic stewardship program, which could potentially affect any resident requiring antibiotics for infections. During an interview, the infection preventionist (IP), who had been in the role for two weeks, acknowledged the absence of a functioning program and expressed the intention to rebuild it. The existing policy, which was undated and only one page long, indicated that the IP would track and assess all antibiotic use to ensure appropriate usage. However, the policy lacked specific protocols and criteria for determining appropriate antibiotic use.
Failure to Monitor Orthostatic Blood Pressure in Residents on Psychotropic Medications
Penalty
Summary
The facility failed to ensure orthostatic blood pressure monitoring was conducted for residents on psychotropic medications, as required for monitoring potential side effects. This deficiency was identified for four out of five residents reviewed, who were on various psychotropic medications for conditions such as schizophrenia, anxiety, depression, and bipolar disorder. Despite having orders for orthostatic blood pressure monitoring, the treatment administration records for these residents lacked documentation of such monitoring over several months. Resident 1, who had intact cognition and was on antidepressant, antianxiety, and antipsychotic medications, had orders for orthostatic blood pressure monitoring that were not documented in the treatment administration records from May to July 2024. Although the resident refused monitoring in August 2024, the facility's records still lacked documentation of any orthostatic blood pressure readings. Similarly, Resident 8, with diagnoses including bipolar disorder and schizophrenia, also had no documented orthostatic blood pressure monitoring despite having orders for it. Resident 13, who was on multiple psychotropic medications, had sporadic documentation of blood pressure readings, but these were incomplete and did not consistently include all required positions (lying, sitting, standing). Resident 5, with a history of seizure disorder and schizophrenia, also lacked documented orthostatic blood pressure monitoring. The interim Director of Nursing acknowledged the absence of active orders and documentation for orthostatic blood pressure monitoring, which is crucial for assessing the effectiveness and side effects of psychotropic medications.
Failure to Notify Physician of Resident's COVID-19 Test and Symptoms
Penalty
Summary
The facility failed to notify and consult with a resident's physician after the resident was tested for COVID-19. The resident, who had intact cognition and a history of respiratory issues, including emphysema, reported symptoms such as a harsh cough, difficulty breathing, and feeling unwell over several days. Despite these symptoms, the resident's electronic health record lacked documentation of a COVID test or result, and there was no evidence that the physician was notified of the resident's condition or test results. The resident expressed concerns about her health to staff multiple times, including requesting a COVID test and assistance in going to urgent care. However, staff did not promptly address her requests or document her symptoms and test results. The Director of Nursing was only made aware of the resident's respiratory symptoms when the resident requested to call 911 herself. The DON confirmed that the COVID test was negative but acknowledged that the results were not documented in the resident's health record, nor was the physician notified.
Failure to Ensure Resident Privacy
Penalty
Summary
The facility failed to ensure personal privacy for a resident, identified as R8, who was reviewed for privacy concerns. R8, who had intact cognition and was independent with activities of daily living, had diagnoses of anxiety, bipolar disorder, and schizophrenia. The resident experienced hallucinations and delusions and exhibited behavioral symptoms. A progress note indicated that staff entered R8's room without waiting for a response after knocking, which made R8 uncomfortable as she was changing clothes at the time. R8 expressed a desire for privacy curtains, especially when changing clothes, but her care plan lacked documentation of her privacy preferences or assessment. Observations revealed that R8's shared bedroom did not have privacy curtains or screens, and interviews with staff confirmed the lack of privacy provisions in resident rooms. An LPN mentioned that residents needing privacy would have to go to the nursing office or bathroom. The DON acknowledged the absence of privacy curtains and stated that the facility was considering installing them. The facility's policy on resident privacy indicated that residents could request privacy screens, but some beds could not accommodate them due to accident hazards. The policy suggested alternative options, such as moving residents to different beds or rooms, or even discharge, to meet privacy needs.
Failure to Report and Investigate Fire Incident
Penalty
Summary
The facility failed to recognize and report a potential incident of neglect to the State Agency (SA) after a fire occurred in the smoking room on the second floor. The interim Director of Nursing (DON) was aware of the fire but did not see any investigation report or know if it had been reported to the SA. The Administrator acknowledged the fire and stated that the incident should have been investigated by the social worker (SW), but no investigation was completed, and the incident was not reported to the SA. Interviews revealed that a resident attempted to extinguish the fire but was unable to do so, and a cook eventually put out the fire. The fire department was called and arrived after the fire was extinguished. The facility's policy on Abuse, Neglect, and Exploitation Prevention requires immediate reporting of incidents to the SA and mandates staff training on identifying and reporting such incidents. The infection preventionist (IP) overseeing the DON confirmed the expectation for staff to report incidents to management for further investigation and instructions. Despite these policies, the incident was not reported, and no investigation was conducted, which could potentially affect all residents in the facility.
Failure to Reorder Medications Timely
Penalty
Summary
The facility failed to ensure timely re-ordering of medications for a resident, identified as R1, who was receiving treatment for multiple conditions including schizophrenia, depression, and anxiety. R1's medication administration record indicated she was prescribed sertraline for depression, among other medications. However, during a medication administration observation, it was noted that the sertraline was not available, and the Serevent Diskus was expired. This resulted in R1 not receiving her scheduled doses of sertraline and Serevent Diskus. Interviews with R1 revealed that she experienced feelings of nervousness and restlessness due to the lack of her prescribed medication. R1 expressed confusion and frustration over the facility's failure to reorder medications in a timely manner, stating that this issue had been ongoing. The resident resorted to smoking a cigarette to alleviate her restlessness, indicating the impact of the medication lapse on her mental state. The facility's policy required nurses or trained medication aides to reorder medications when there was less than a five-day supply. However, the review of refill reorder forms showed a lack of documentation for the reordering of sertraline. Interviews with the LPN and the DON confirmed that it was the nurses' responsibility to input new orders and request refills. The DON mentioned a new process for reordering medications, but it was not effectively implemented, leading to the deficiency observed.
Failure to Recognize Change in Respiratory Status
Penalty
Summary
The facility failed to recognize a change in respiratory status for a resident with a history of respiratory issues, including COPD and emphysema. The resident, who had intact cognition and was aware of her symptoms, reported shortness of breath and other respiratory symptoms to the staff on multiple occasions. Despite these reports, the facility did not adequately assess or document the resident's respiratory condition, nor did they follow up on her requests for a COVID test in a timely manner. The resident's medical records indicated she was on several medications for respiratory issues, including albuterol and Serevent Diskus. However, there was a lack of documentation in her care plan regarding her respiratory status. The resident experienced worsening symptoms, including a harsh cough and difficulty breathing, which she reported to staff. Despite her complaints, staff did not perform a thorough assessment, such as listening to her lung sounds, and there was no documentation of her COVID test results in her electronic health record. The situation escalated when the resident, feeling unwell and short of breath, requested to go to urgent care and asked staff to call 911. The staff, including the DON, did not comply with her request, leading the resident to call an ambulance herself. The DON acknowledged the resident's request for a COVID test and confirmed it was negative, but there was no documentation of this in the resident's records. The facility's failure to adequately assess and document the resident's respiratory condition and respond to her requests for medical attention and testing contributed to the deficiency.
Failure to Implement Smoking Safety Interventions
Penalty
Summary
The facility failed to implement smoking interventions to reduce the risk of avoidable injuries for a resident with a history of injuries related to smoking. The resident, who had diagnoses including depression, schizophrenia, and asthma, was assessed multiple times for smoking safety, with instructions that all smoking supplies should be stored in the nursing office. Despite this, observations revealed that the resident had access to a lighter in her room and was able to independently light cigarettes in the smoking room without staff intervention. Interviews with facility staff, including a CNA and the DON, indicated a lack of awareness and communication regarding which residents were allowed to keep smoking materials. The CNA was not informed about any restrictions on residents keeping smoking materials, and the DON, upon reviewing the resident's assessments and care plan, acknowledged that the resident should not have been allowed to keep her lighter. The facility did not provide a policy regarding safe smoking practices when requested.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate during a medication pass observation. This deficiency involved two errors out of 25 opportunities, specifically affecting one resident. The resident, who was cognitively intact and independent in most activities of daily living, had a history of anxiety disorder, depression, and chronic obstructive pulmonary disease. The resident was prescribed Sertraline HCl for major depressive disorder and Serevent Diskus for shortness of breath. However, during the medication pass, the LPN was unable to locate the Sertraline HCl medication card, and the Serevent Diskus was found to be expired, leading to the resident not receiving either medication. Interviews with the LPN and the interim DON revealed that it was the nurses' responsibility to input new orders, send them to the pharmacy, and request medication refills. The interim DON stated that medications should be reordered when there was a week's worth of medication left. Despite this, the facility was unable to provide a policy regarding medication reordering. This lack of policy and oversight contributed to the medication errors observed during the survey.
Deficiency in Resident Room Square Footage
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in three resident bedrooms, affecting nine residents. Specifically, the rooms in question did not meet the regulatory requirement of at least 80 square feet per resident in multiple occupancy rooms. Room 101 housed three residents with only 65.9 square feet per resident, room 102 housed three residents with 79.6 square feet per resident, and room 103 housed three residents with 73.6 square feet per resident. Despite these deficiencies, the rooms were observed to pose no safety hazards and were adequately furnished. There was no evidence that the residents were negatively impacted by the room size. The facility's administrator confirmed that there had been no changes or updates to the rooms since the prior survey.
Medication Administration Error Due to Documentation and Communication Failures
Penalty
Summary
The facility failed to ensure a once-monthly injection was administered per physician orders, resulting in a significant medication error for a resident diagnosed with schizoaffective disorder, bipolar disorder, and extrapyramidal movement disorder. The resident was supposed to receive an Invega Sustenna injection every 28 days, but due to a series of miscommunications and documentation errors, the injection was administered twice over two consecutive days. The initial dose was missed in June, and upon discovery, the nursing staff attempted to rectify the situation by administering the injection on July 3rd. However, due to a lack of proper documentation and communication, the injection was administered again on July 4th. The sequence of events leading to the error involved multiple staff members, including LPNs and DONs, who were involved in the administration and documentation process. On July 3rd, the DON instructed an LPN to administer the injection after receiving a verbal order from a nurse practitioner. However, the LPN did not document the administration in the electronic medical record, leading to another LPN administering the same injection the following day. The second administration occurred after the DON from a sister facility checked the records and found no documentation of the previous day's injection. The facility's policy on administering medications requires verification of the right resident, medication, dosage, time, and method before administration. However, the lack of proper documentation and communication among staff members led to the medication being administered twice. The resident was monitored for adverse effects, but none were reported. The facility did not provide a policy on verbal and written orders, and the staff involved had received education on medication administration, but the incident highlighted gaps in the process.
Discrepancies in Resident Trust Fund Accounting and Failure to Provide Quarterly Statements
Penalty
Summary
The facility failed to maintain a system that assured full and complete accounting of resident personal funds entrusted to the facility, affecting 14 residents with trust fund accounts. The director of nursing (DON) confirmed discrepancies in the petty cash amounts, with a total of $36.20 unaccounted for. Additionally, the facility's electronic health record (EHR) system showed a significant discrepancy of $7,025.76 between the resident trust fund total balances in the EHR and the bank account transaction statements. The chief financial officer (CFO) acknowledged the discrepancies and was attempting to reconcile the accounts but had not yet identified the source of the errors. The facility also failed to provide quarterly statements for individual resident trust fund accounts for 5 of the 14 residents reviewed. Interviews with residents and their representatives revealed that they had not received the required quarterly statements, with some indicating they had never received such statements. The administrator and CFO confirmed that the statements were supposed to be sent out quarterly, but there was no documentation to prove that the most recent statements had been distributed. The administrator and CFO provided conflicting information about the process and responsibility for distributing the statements. The facility's policy required maintaining a written record of all financial transactions involving a resident's personal funds and providing quarterly statements to residents or their representatives. However, the facility failed to adhere to this policy, resulting in unaccounted funds and a lack of transparency for the residents and their representatives. The discrepancies in the accounting system and the failure to provide quarterly statements indicate a significant lapse in the facility's financial management and oversight of resident trust funds.
Inadequate Surety Bond for Resident Trust Fund
Penalty
Summary
The facility failed to ensure the surety bond contained sufficient funds to insure and protect the total balance of the resident trust fund. The transaction history for the facility's resident trust fund savings and checking accounts from 4/1/24 to 4/11/24 identified a combined total balance of $24,419.88 on 4/11/24. However, the facility's surety bond, effective from 9/9/23, was for a sum of $20,000, which was inadequate to cover the balance of the resident trust fund. During an interview on 4/15/24, the CFO acknowledged that the surety bond did not cover the balance of $24,419.88 in the resident trust fund accounts. The facility policy dated 10/6/22 stated that the facility maintains a surety bond to ensure the security of all personal funds deposited with the facility, which was not adhered to in this instance.
Failure to Update Care Plan for Resident with History of Leaving Facility
Penalty
Summary
The facility failed to update a care plan to include a resident's history of leaving the facility against the leave of absence policy. The resident, who had diagnoses including paranoid schizophrenia, post-traumatic stress disorder, schizoaffective disorder, delusional disorders, and major depressive disorder, left the facility multiple times without informing the staff of her whereabouts or return plans. Despite the resident's repeated absences, her care plan did not reflect her noncompliance with the leave of absence policy. This oversight was noted during interviews and document reviews, where it was revealed that the care plan was not updated to address the resident's behavior and associated risks. The deficiency was further highlighted by the fact that the resident's medication administration record indicated she received her scheduled medications despite her absences, suggesting a lack of accurate documentation and monitoring. Staff members, including LPNs and the DON, acknowledged that any changes to a resident's care should be noted in their care plan and that the care plan should be updated as the resident's condition changes. However, the care plan for this resident was not updated, and the weekend nursing staff, who were agency nurses, may not have had the appropriate administrative privileges to make necessary updates in the electronic medical record system.
Latest citations in Minnesota
A resident with intact cognition and multiple diagnoses, including AFib, HF, stroke, anxiety, and depression, was permitted to self-administer nebulizer treatments after staff setup without an IDT self-administration assessment. The EMR lacked documentation of the resident’s competency and safety to manage the nebulizer, including understanding the medication, following directions, operating the equipment, recognizing side effects, and storing the medication and equipment. Staff and the DON confirmed the assessment had not been completed before the self-administration order was implemented.
Failure to Assess and Monitor Antipsychotic Use: A resident with severe cognitive impairment, dementia, anxiety, and mood disorder received Risperidone for agitation and paranoia, but the EMR did not show an AIMS assessment on admission or timely target behavior monitoring. The RN case manager and DON confirmed that baseline AIMS and ongoing behavior monitoring should have been in place when the antipsychotic was started, but the resident’s record lacked measurable target behaviors and documentation of medication effectiveness.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs: The facility failed to include key diagnoses, devices, and medication-related risks in care plans for two residents. One resident’s plan did not address Eliquis use, cardiac conditions, pacemaker presence, or condom catheter care, and another resident’s plan did not address Eliquis therapy or related bleeding-risk monitoring. The DON and RN case manager confirmed these items should have been care planned.
Failure to provide scheduled bathing and grooming assistance: Two residents with intact cognition and ADL dependence did not receive bathing as documented on a weekly schedule, and one resident also had unaddressed facial hair and greasy, unkempt hair. Records did not show consistent weekly baths, additional refusals, or reasons for missed care, and staff interviews confirmed residents were expected to receive at least weekly bathing unless they refused and that facial hair should be shaved when noticed.
A resident with intact cognition and multiple diagnoses, including BPH and stroke, had a physician order for a condom catheter at bedtime, but the EMR lacked orders or instructions for cleaning, disinfecting, monitoring, or changing the drainage bag. During observation, the bag was seen hanging in the bathroom, and an LPN, RN case manager, and DON all confirmed the absence of documented guidance for the catheter drainage bag care.
Failure to preserve dignity occurred when staff placed a brief on a cognitively intact resident who was continent of bowel and bladder. The resident stated the brief made him feel like a baby, and a NA confirmed she applied it even though he was not incontinent; RN and DON both verified the resident was continent and that briefs should not be placed on continent residents.
Failure to provide restorative ambulation and respond to a decline in mobility: A resident with dementia, weakness, chronic pain, and limited physical mobility was care planned for daily ambulation with a FWW and staff assist of 1, but the rehab record repeatedly showed ambulation as not applicable and staff interviews confirmed the task was often not done. The resident stated she could no longer walk, staff reported she had not walked for weeks and now required a sit-to-stand lift with assist of 2 for transfers, and the chart lacked an ADL decline assessment or revision of the ambulation care plan.
A resident with mild cognitive impairment, hemiplegia, hemiparesis, and limited ROM had restorative orders for PROM, stretching, and hand splints, but staff did not consistently offer or complete the interventions. Documentation showed the splints were sometimes marked not applicable instead of refused, and leg stretches were completed only a few times with no explanation for missed care. Staff interviews confirmed the restorative tasks often were not done, and the DON stated the resident’s restorative program needed to be updated.
Dirty can opener and contaminated dry storage bins: The DCS observed four labeled dry-goods bins with dirty rims, dry matter on the bin walls, and a scoop left inside a flour bin with flour on it. The attached can opener also had dry red matter on the blade, and the cook said it had been used that morning to open cream of corn for lunch. The DCS verified the findings and stated the can opener should be washed after each use and the dry bins and scoops should be kept clean.
Dignified Medication Administration Not Maintained: A resident with severe dementia, hallucinations, anxiety, PTSD, and delusional disorder was observed during med pass in the dining room. An RN attempted to administer meds by pouring them from a plastic cup into the resident’s mouth, continued despite the resident pulling away and moving her head, and then raised her voice and questioned why the resident would not take the meds after one pill was spit out and thrown on the floor. The resident stated the nurse was not being nice, and the RN left with the refused meds.
Missing Self-Administration Assessment for Nebulizer Use
Penalty
Summary
The facility failed to ensure an interdisciplinary team (IDT) assessment was completed before allowing a resident to self-administer nebulizer treatments. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders showed Ipratropium-Albuterol nebulizer treatments three times daily, and the EMR later included an order permitting the resident to self-administer nebulizer treatments after staff setup, but there was no evidence that an IDT self-administration assessment had been completed first. The record also lacked documentation showing the resident’s competency and safety to self-administer the nebulizer medication and treatment, including the ability to understand the medication purpose, follow directions, safely operate the equipment, recognize side effects or adverse reactions, and ensure safe administration and storage. During observation, the resident had nebulizer equipment and medication available in the room. The resident stated staff set up the medication cup and left while the treatment ran, then returned to ensure the machine was turned off; staff cleaned the nebulizer mask afterward. An LPN and RN confirmed the treatment was set up by staff, and the RN and DON stated a self-administration assessment should have been completed before the resident was permitted to self-administer medications.
Failure to Assess and Monitor Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications was adequately assessed and monitored. R3’s admission MDS identified severe cognitive impairment and the need for assistance with ADLs, with diagnoses including non-traumatic brain dysfunction, unspecified dementia without behavioral, psychological, mood, or anxiety disturbances, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder. The resident’s physician orders included Risperidone 0.25 mg, two tablets by mouth every four hours PRN for agitation and paranoia, with a maximum of three PRN doses in 24 hours, and Risperidone 0.5 mg, one tablet by mouth three times daily for paranoia/agitation. R3’s EMR did not show that an AIMS assessment was completed upon admission despite the resident receiving antipsychotic medication, and the assessment was only completed after surveyor request. The record also lacked evidence that target behavior monitoring had been initiated for the antipsychotic use, with no measurable target behaviors documented, including frequency, duration, severity, precipitating factors, or response to interventions for agitation and paranoia. Interviews with the RN case manager and DON confirmed that AIMS assessment and behavior monitoring should have been completed upon admission or initiation of antipsychotic medications, and both acknowledged that target behavior monitoring had not been initiated.
Incomplete Care Plans for Anticoagulant Therapy and Cardiac-Related Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with significant medical conditions and medication-related needs. One resident had intact cognition and diagnoses including atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, depression, and a cardiac pacemaker, and was receiving Eliquis. The resident also had a physician order for a condom catheter at bedtime and removal when getting up for the day. The comprehensive care plan printed 5/20/26 did not identify interventions or monitoring related to anticoagulant use, including bleeding risk, adverse effect monitoring, or staff awareness of anticoagulant precautions, and it also lacked interventions related to the resident’s cardiac conditions, pacemaker, and condom catheter use, including skin integrity monitoring and resident-specific catheter care preferences. A second resident with severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, unspecified dementia, non-Alzheimer’s dementia, anxiety disorder, and mood affective disorder was also receiving Eliquis. The resident’s comprehensive care plan printed 5/19/26 did not include anticoagulant therapy, bleeding risk precautions, monitoring for adverse effects, or other interventions related to anticoagulant medication use. During interviews, the RN case manager and DON confirmed that anticoagulant therapy, the condom catheter, cardiac conditions, and pacemaker presence should have been addressed on the care plans and acknowledged that these items were not included.
Failure to Provide Scheduled Bathing and Grooming Assistance
Penalty
Summary
The facility failed to ensure that two residents who required assistance with activities of daily living received routine bathing and grooming services needed to maintain personal hygiene and dignity. R2’s MDS identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care while honoring personal hygiene preferences. R21’s MDS also identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care. R2’s bathing record showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. Baths were documented on several dates, but the time between some baths exceeded one week, and the record did not show additional refusals or reasons why scheduled baths were missed. During observation, R2’s hair was messy and greasy, and long white chin hairs were present. R2 stated she did not get baths very often because the facility was short staffed and said she did not have access to tweezers, a shaver, or a mirror. The EMR did not document that grooming assistance had been offered or provided for facial hair care. R21’s bathing record also showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. The record showed one refusal and several baths, but some intervals between baths exceeded one week, and there was no documentation of additional refusals or reasons for missed baths. R21 stated she had been in the facility since mid-April and had yet to have a bath or shower, and said staff were waiting for physician approval because of wounds, though that had been a while. R21 also stated she had only had her hair washed once with a shampoo shower cap while in bed. Staff interviews confirmed residents were expected to receive at least one bath weekly unless they refused, refusals should be documented, and facial hair should be addressed when noticed.
Missing Orders and Documentation for Condom Catheter Drainage Bag Care
Penalty
Summary
The facility failed to ensure appropriate care and services were provided for management of a resident’s external urinary catheter system. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders dated 4/29/26 indicated use of a condom catheter at bedtime, but the electronic medical record did not contain physician orders or documented instructions for cleaning, disinfecting, monitoring, or routinely changing the associated catheter drainage bag. During observation on 5/19/26 at 11:57 a.m., the resident’s catheter drainage bag was seen hanging on the side rail in the bathroom. Record review and observation did not identify documentation that the drainage bag was routinely cleaned, disinfected, monitored, or replaced according to accepted standards of practice. An LPN confirmed there were no physician orders addressing when the drainage bag should be changed or instructions for cleaning or disinfecting it. An RN case manager stated the drainage bag should have been changed weekly, but no orders related to changing, cleaning, or disinfecting were present. The DON stated the facility expected clear physician orders and nursing instructions for catheter care, cleaning, monitoring, and replacement schedules, and confirmed the facility could not provide evidence that such orders or guidance were in place for the resident’s condom catheter drainage bag care.
Failure to Preserve Dignity by Placing a Brief on a Continent Resident
Penalty
Summary
The facility failed to provide services in a dignified manner for 1 resident who was cognitively intact and had diagnoses including renal insufficiency, DM, and hypertension. The resident’s MDS identified him as continent of bowel and bladder and needing staff assistance with ADLs including bed mobility, transfers, and toileting. A bowel and bladder assessment also identified the resident as continent, and the care plan stated he was aware of the need to void or defecate and would request to use the toilet as needed. During interview, the resident stated staff put diapers on him even though he was not incontinent and said it made him feel like a baby. During observation, a NA placed a brief on the resident, and the resident showed the surveyor the brief and stated it had just been put on him a few minutes earlier. The NA verified she placed a brief on the resident that morning even though he was not incontinent and said she was unsure why she did so. RN-A confirmed the resident was continent and stated staff put a brief on him out of habit. The DON stated staff should not place a brief on residents who are continent and that it was important to maintain the resident’s dignity.
Failure to Provide Restorative Ambulation and Address Decline in Mobility
Penalty
Summary
The facility failed to provide restorative ambulation services and failed to respond to a decline in ambulation status for one resident who had mild cognitive impairment, dementia, hypertension, diabetes, weakness, and chronic pain. The resident’s care plan and restorative documentation directed daily ambulation with a front wheeled walker and staff assistance of one, and the resident was also identified as having limited physical mobility and being at risk for falls due to weakness, chronic pain, and an unsteadied gait and balance. However, the nursing rehab point-of-care record repeatedly documented ambulation as “not applicable,” with only one entry showing the resident ambulated for 15 minutes and one entry showing refusal. The resident stated she could no longer walk and that staff needed to help her get into bed and her wheelchair. Staff interviews confirmed the ambulation task was not being completed. A nursing assistant stated aides were responsible for ambulation but were not completing it, and another nursing assistant stated ambulation was supposed to be done but was not done very often; that staff documented it as not applicable when it did not get done; and that the resident had not walked at all for several weeks and was using a sit-to-stand lift with assist of two for all transfers. An RN stated the task just did not get done and that no plan had been created to fix it. The DON stated the resident’s condition had changed and a therapy evaluation should have been requested, and also stated the care plan needed revision because the resident would not be transferred with an assist of one. The resident’s medical record lacked an assessment for ADL decline, including any revision to the ambulation care plan.
Failure to Complete and Document Restorative ROM and Splinting
Penalty
Summary
The facility failed to ensure range of motion (ROM) was completed in accordance with therapy recommendations to maintain mobility for one resident with mild cognitive impairment who was dependent on staff for all care areas and had diagnoses including diabetes, hemiplegia, and hemiparesis. The resident’s care plan identified limited physical mobility, fall risk, weakness, contractures, and limited ROM, and included restorative nursing interventions for bilateral lower extremity passive ROM to active ROM, passive hamstring and heel cord stretches, PROM to both hands, and splint use for the hands. The resident’s restorative documentation from 4/20/26 through 5/19/26 showed the hand splints were worn 41 times and marked not applicable 20 times out of 90 opportunities, but the documentation did not identify refusals to wear the splints. The leg stretches were completed 3 times out of 30 opportunities, and the documentation did not identify why the stretches were not performed or whether they were refused. The resident’s untitled nurse aide care sheet also identified a restorative program and encouragement to participate in the Well Fit program. During interviews, a nursing assistant stated staff were supposed to encourage participation in the Well Fit program and complete PROM and AROM, but it did not get done very often and was often documented as not applicable because it was not offered. An RN stated nursing assistants were responsible for restorative programs but they did not get done, and no plan had been created to fix the issue. The DON stated staff should have offered the tasks and documented refusals, but believed staff may have stopped offering after repeated refusals; the DON also stated the restorative program needed to be updated and that staff were documenting tasks as not applicable, which she was unaware of.
Dirty can opener and contaminated dry storage bins
Penalty
Summary
The facility failed to keep 1 of 1 commercial can opener clean and sanitary and failed to store dry goods removed from original packaging in a manner that reduced the risk of cross-contamination. During an initial tour with the Director of Culinary Services (DCS), four white plastic bins in the food preparation area were observed on the floor and labeled for flour, white sugar, rice, and powdered sugar. The flour bin was about one-third full and had a black scoop partially covered with flour, including the handle. The bin labeled white sugar had yellowish-tan dry matter on the right lateral wall, and the front wall had red dry matter measuring 6-7 cm in diameter. The rims around the lids of all four bins were dirty with dark dust-like particles, and the DCS verified these findings and stated the scoop should not be left inside the bins and needed to be clean inside and out. The attached [NAME] brand can opener was also observed with its blade halfway covered with dry, red-colored matter. On a later kitchen tour, the can opener blade still had dry red matter, which had been pushed upward by 0.2 cm, and a small light amber particle was noted below it. The cook stated he had used the can opener that morning to open a can of cream of corn used for lunch. The DCS verified the dry matter on the can opener and stated it should be washed every time it was used to prevent cross contamination. Facility policy stated dry storage areas would be maintained to keep food safe and free of infestation or contamination, and the sample cleaning schedule stated can openers should be clean after each use.
Dignified Medication Administration Not Maintained
Penalty
Summary
The facility failed to provide a dignified experience for 1 of 2 residents, R20, during medication administration. R20’s records showed severely impaired cognition, inattention, disorganized thinking, verbal behaviors toward others, and diagnoses including severe dementia with psychotic disturbance, visual hallucinations, generalized anxiety disorder, PTSD, and delusional disorder. Her care plan identified mood, behavior, and sleep alterations related to Alzheimer’s disease, dementia, generalized anxiety disorder, paranoia, public outbursts, and accusations that people were throwing medications down her throat, and it directed staff to redirect and reapproach when she was resistive or combative, use a calm approach, provide reassurance, and offer comfort items. During observation, RN-A brought medications to R20 in the dining room and attempted to pour them from a small plastic cup into her mouth. When R20 removed one medication, Divalproex, and threw it on the floor, RN-A attempted again to pour the remaining medications into her mouth while R20 moved her head back and forth and tried to pull away. RN-A then raised her voice, stated the resident’s name, told her she needed to take her medications, pulled her chair back from the table, picked up the Divalproex from the floor, placed it in a separate cup, and asked why she would not take her medications. R20 responded that it was because the nurse was not being nice. RN-A then left with the remaining refused medications and stated R20 would take them later and that she always had a behavior when taking her morning medications.
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