Minnesota Veterans Home - Silver Bay
Inspection history, citations, penalties and survey trends for this long-term care facility in Silver Bay, Minnesota.
- Location
- 56 Outer Drive, Silver Bay, Minnesota 55614
- CMS Provider Number
- 245628
- Inspections on file
- 18
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Minnesota Veterans Home - Silver Bay during CMS and state inspections, most recent first.
Medications Left at Bedside Without Self-Administration Approval: A resident with renal insufficiency, anxiety, and depression had a SAM assessment indicating the resident did not want to self-administer and was no longer able to do so, yet nicotine throat lozenges were observed on the bedside table with no staff present. The resident’s orders and care plan lacked bedside-medication/self-administration instructions, and staff interviews confirmed a SAM assessment and order were needed before medications could be left at bedside.
Medication Administered Not Per Provider Order: A cognitively intact resident with renal insufficiency, anxiety, and depression had an order for nicotine throat lozenge 4 mg, one lozenge PO every hour PRN, but staff were observed giving two lozenges at a time. The TMA confirmed the order was for one lozenge and stated staff had been giving the resident two lozenges, while the RN and DON stated medications should only be administered as ordered.
A resident with stroke, hemiplegia, and dysphagia was care planned for a regular diet with thin liquids, bite-size food, and assist of one with meals, but staff did not follow those interventions. Observations showed meatloaf and coffee cake were served without being cut up, and no staff were present to assist while the resident ate. The cook said food should have been cut into bite-size pieces, while an NA said she was not aware she was assigned to assist with all meals.
A resident who was cognitively intact and dependent for toileting received incontinent care in which an NA cleaned the peri area, then continued with the same contaminated gloves while placing a clean brief, dressing the resident, and handling supplies. The clean brief contacted the soiled brief during the process, and interviews with the NA, RN, IP, and DON confirmed gloves should be changed when moving from dirty to clean parts of care; the facility hand hygiene policy addressed hand hygiene before and after resident cares.
Failure to timely report alleged physical abuse: A resident reported that an NA grabbed the resident’s left hand in a not gentle manner, causing pain and possible bruising. The incident was documented in the facility report and progress note, but the allegation was not reported to the SA within the required 2-hour timeframe; staff interviews indicated the report was not made until the next morning after the day nurse was informed.
A resident with multiple health conditions received another resident's medications due to a nurse preparing multiple residents' medications simultaneously. This error led to the resident experiencing bradycardia and hypotension, requiring emergency department care. The nurse involved was removed from medication duties and re-educated on proper practices.
Medications Left at Bedside Without Self-Administration Approval
Penalty
Summary
The facility failed to ensure medications were not left at a resident bedside when the resident was assessed as unable to self-administer medications. The deficiency involved one resident whose quarterly MDS indicated cognitive intactness and whose diagnoses included renal insufficiency, anxiety, and depression. The resident’s Provider Order Summary Report lacked orders to keep medications at bedside, and the care plan lacked information related to self-administration of medications. The resident’s Self Administration of Medications &/or Treatments assessment dated 3/20/26 indicated the resident did not want to self-administer medications and was no longer able to self-administer. Despite this, during observations on 4/13/26 and 4/14/26, two white pills identified by the resident as nicotine throat lozenges were observed on the bedside table with no staff present in the room. During interviews, a TMA stated she very rarely leaves medications at bedside and was unsure what needed to be in place for medications to remain there when staff were not present, and confirmed the resident had nicotine throat lozenges left at bedside. An RN stated a SAM assessment and order needed to be in place before medications could be left at bedside so the resident could self-administer. The DON stated the SAM assessment needed to indicate the resident wanted to self-administer and was able to self-administer before medications could be left at bedside, and that staff were expected to confirm the appropriate information before leaving medications at bedside. Facility policy stated a comprehensive assessment would be completed to ensure the resident wanted to and had the capability to self-administer medications and keep medications at bedside.
Medication Administered Not Per Provider Order
Penalty
Summary
The facility failed to follow provider orders and administer medications as ordered for one resident who was cognitively intact and had diagnoses including renal insufficiency, anxiety, and depression. The resident had an order for nicotine throat lozenge 4 mg, one lozenge by mouth every hour as needed. During observation, two white pills identified by the resident as nicotine throat lozenges were seen on the bedside table, and later the resident requested two nicotine throat lozenges. At that time, a TMA entered the room with a medication cup containing two nicotine throat lozenges and gave both to the resident. The TMA stated medications should only be administered according to the provider's order, confirmed she gave two lozenges even though the order was for one at a time every hour as needed, and stated staff had been giving the resident two lozenges at a time. The RN and DON stated medications should only be administered as ordered by the provider, and the facility policy indicated staff would ensure the correct medication and correct dose were only administered based on the provider order.
Failure to Follow Meal Assistance and Bite-Size Food Care Plan
Penalty
Summary
The facility failed to implement and follow interventions for a resident who required assistance with meals. The resident’s quarterly MDS identified him as cognitively intact, with diagnoses including stroke, hemiplegia, and dysphagia. His care plan identified a regular diet with thin liquids, with all foods needing to be cut into bite-size pieces and assistance of one with meals. The East Dining Assistance Roster also identified him as an assist of one for meals, and care conference notes documented that he agreed to a bite-size diet and assist of one with meals, with the care plan updated. During observation, the resident was served mashed potatoes with gravy and a piece of meatloaf, and he began feeding himself while the meatloaf was not cut into bite-size pieces and no staff were present to assist him. On another observation, he received a piece of coffee cake that was not cut up and again ate without staff around to assist. The cook stated the food should have been cut into bite-size pieces and that cooks were responsible for cutting food, while the nursing assistant stated she was not aware she was an assist for all meals and did not stay with him while he ate. The RN stated the resident had agreed to bite-sized food and assistance with meals, and the DON stated staff were expected to follow the care plan and provide care based on the care plan.
Infection Control Lapse During Incontinent Care
Penalty
Summary
Provide and implement an infection prevention and control program was not completed during incontinent care for one cognitively intact resident with diagnoses of stroke and cancer who was frequently incontinent of bladder and always incontinent of bowel and required maximum assistance with toileting. The resident’s care plan directed staff to check and change the brief and provide perineal care. During observation, a nurse assistant entered the room, washed hands, donned gloves, and gathered supplies to change the resident’s saturated brief and clean the peri area. While performing the care, the nurse assistant cleaned the front peri area and buttock region, then rolled the dirty brief and the clean brief together so the clean brief came into contact with the soiled brief. The disposable chuck under the resident had wet areas where the peri-area would be located. With the same contaminated gloves still on, the nurse assistant placed the new brief, secured it, transferred the resident to a wheelchair, dressed him, and returned peri care supplies to the closet while touching several items. Interviews with the NA, RN, IP, and DON confirmed gloves should be changed when moving from dirty to clean parts of care, and the facility policy stated staff would perform hand hygiene before and after resident cares.
Failure to Timely Report Alleged Physical Abuse
Penalty
Summary
The facility failed to report an allegation of staff-on-resident physical abuse within two hours to the State Agency for one resident, R54. On 6/6/25 at about 8:00 p.m., R54 reported that a nurse assistant grabbed the resident’s left hand in a not gentle manner, causing pain and possible new bruising. A facility incident report later documented that R54 was handled roughly by a staff member and came into contact with the left hand, causing injury and pain. In a progress note entered at 10:39 p.m. on 6/6/25, staff documented that the resident complained the nurse assistant had grabbed the left hand roughly and caused pain and injury. During interview, RN-C stated R54 reported the concern to her around 8:00 p.m. and she could not remember whether she notified anyone right away. The infection preventionist stated the complaint was not reported to the State Agency until about 10:15 a.m. on 6/7/25, after the day nurse informed her. Facility policy required all allegations of abuse, neglect, exploitation, or mistreatment to be reported no later than two hours after the allegation was made.
Medication Error Leads to Resident Harm
Penalty
Summary
The facility failed to ensure medications were administered to the correct resident, resulting in a significant medication error for one resident. This resident, who had intact cognition and multiple diagnoses including chronic kidney disease, hypertension, and heart failure, was mistakenly given another resident's medications. The error occurred when a registered nurse (RN) prepared medications for multiple residents simultaneously and inadvertently administered the wrong set to the resident in question. Following the administration of incorrect medications, the resident developed symptoms of bradycardia and hypotension, including severe dizziness, which necessitated emergency department evaluation and treatment. The resident's blood pressure and pulse were significantly low, prompting the nurse practitioner to order immediate hospital transfer. The resident's hospital records confirmed the administration of incorrect medications and detailed the resulting symptoms, including lightheadedness and weakness. The RN involved in the incident admitted to setting up medications for three residents at once, which led to the error. Upon realizing the mistake, the RN reported it to the charge nurse, who then took over the resident's care. The RN was subsequently removed from medication administration duties and later re-educated on proper medication administration practices. The facility's consultant pharmacist and nurse practitioner both emphasized the importance of preparing medications for one resident at a time to prevent such errors.
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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