Mn Veterans Home Fergus Falls
Inspection history, citations, penalties and survey trends for this long-term care facility in Fergus Falls, Minnesota.
- Location
- 1821 North Park, Fergus Falls, Minnesota 56537
- CMS Provider Number
- 245636
- Inspections on file
- 23
- Latest survey
- May 6, 2026
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Mn Veterans Home Fergus Falls during CMS and state inspections, most recent first.
A resident with dementia and a history of sundowning, verbal aggression, and wandering was in his room when another cognitively impaired, behaviorally aggressive resident entered unsupervised, moved belongings, allegedly grabbed the resident by the neck, and threw him to the floor, leaving with the resident’s cane. Staff later found the resident on the floor with bruising and swelling to his elbow and additional bruising to his buttock and opposite elbow. The aggressive resident had a well-documented pattern of wandering into other rooms, taking items, and becoming physically aggressive when confronted, and his care plan directed frequent monitoring of his whereabouts due to these behaviors. Despite this, he was able to enter another resident’s room and, even after the incident, continued to wander into other rooms without adequate supervision, demonstrating a failure to protect residents from physical abuse.
A resident with severe cognitive and physical impairments fell and sustained a head injury when staff failed to properly secure a lift sling to a ceiling lift during a transfer. The improper attachment of the sling strap was not double-checked, leading to the strap detaching and the resident falling to the floor. The resident required emergency evaluation and pain management as a result of the incident.
A resident with severe cognitive impairment fell from a ceiling lift during a transfer when a sling strap was not fully secured, resulting in head and arm injuries. After the incident, the same lift was used for additional transfers, and staff involved continued to perform transfers before receiving retraining or competency checks, contrary to facility policy requiring removal of equipment and staff restriction pending investigation. This failure exposed other residents needing total body lift transfers to potential harm.
A resident with severe cognitive impairment and a history of COPD, hypertension, and stroke was allowed to smoke independently, despite observations of unsafe smoking practices leading to burn-holes in their clothing. The facility's smoking assessments inaccurately reported no visible holes, and staff conducted assessments through a window rather than directly observing the resident in the smoking room. The facility's policy required individualized smoking interventions, but the deficiency in implementing these interventions was evident.
A resident with type two diabetes received insulin without the pen being primed, contrary to manufacturer's instructions. The RN administered 12 units of Semglee insulin without performing the necessary airshot to remove air bubbles, which is essential for accurate dosing. The RN, consultant pharmacist, and DON acknowledged the importance of this step, which was not followed as per the facility's medication administration policy.
Failure to Supervise Aggressive Resident Leads to Resident-to-Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and monitoring to prevent resident-to-resident physical abuse. One resident with dementia, cognitive impairment, and a history of sundowning, verbal aggression, and wandering was seated in his recliner with his room door open when another resident entered his room. The intruding resident, who also had dementia and severe cognitive impairment, was known to wander into other residents’ rooms, touch and take belongings, and had a documented history of verbal and physical aggression toward staff and residents. On the day of the incident, staff later observed this resident exiting the victim’s room carrying the victim’s cane. The victim reported that the other resident came into his room and began moving his belongings. He stated that he got up from his recliner, approached the intruder, and told him to stop. He reported that the other resident then placed his hands around his neck, choked him, and threw him to the floor, taking his cane when leaving the room. Staff responded after hearing the victim yelling and found him on the floor against the wall inside his doorway, with bruising and swelling to his elbow and later bruising to his buttock and the opposite elbow. The victim continued to report pain in his elbow, arm, lower back, and right hand following the incident, and documentation identified contusions and bruising related to the fall caused by the physical aggression of the other resident. The aggressive resident’s record showed a long-standing pattern of wandering into other residents’ rooms, taking or moving their belongings, and provoking or engaging in altercations when confronted. Progress notes documented multiple prior episodes in which he entered peers’ rooms, took walkers or other items, upset other residents, and on several occasions became physically aggressive, including throwing closed-fist punches at a peer and threatening or attempting to hit staff and residents. His care plan directed staff to monitor his whereabouts frequently due to his wandering into private spaces, his tendency to touch and take others’ belongings, and his potential to return aggression when peers became upset with him. Despite these known behaviors and care plan directives, he was able to enter the victim’s room unsupervised, interact with the victim’s belongings, and allegedly choke and throw the victim to the floor, resulting in injury. Following this incident, he continued to wander into other resident rooms unsupervised, demonstrating that the facility did not provide adequate supervision and monitoring to protect residents from physical abuse.
Failure to Ensure Safe Transfer Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to properly attach a lift sling to a ceiling lift bar during a transfer of a resident with severe cognitive and physical impairments. The resident, who had diagnoses including non-traumatic brain dysfunction, Alzheimer's disease, aphasia, seizure disorder, and muscle weakness, was fully dependent on staff for all activities of daily living and transfers. During a transfer from bed to wheelchair, two nursing assistants attached the sling straps to the ceiling lift, but one of the straps was not fully secured. As the resident was lifted, a strap detached, causing the resident to fall from the lift, landing on a floor mat and sustaining a large contusion and hematoma to the back of the head, as well as a skin tear to the forearm. The resident required evaluation in the emergency department and experienced pain requiring medication. The incident was substantiated through staff interviews, reenactments, and document review. It was determined that the left leg sling strap was not properly hooked to the lift bar, and staff did not perform a double-check to ensure all straps were secure before initiating the lift. The facility's procedures and competency checklists did not explicitly require a double-check of sling strap security prior to lifting, and staff involved in the incident did not verify the connections after the resident was slightly lifted off the bed. Additionally, after the fall, the same ceiling lift was used to transfer the resident and another individual before the equipment was inspected, contrary to facility policy requiring removal of equipment from service after an adverse event. Observations and interviews revealed that the sling and lift were appropriate for the resident's care plan at the time, but the failure to ensure proper attachment and verification of the sling straps directly led to the resident's fall and injury. The staff involved did not intentionally cause harm, but the lack of adherence to safety protocols and insufficient verification of equipment setup resulted in actual harm to the resident.
Failure to Protect Residents During Investigation of Lift Transfer Accident
Penalty
Summary
A deficiency occurred when the facility failed to provide sufficient protection to other residents during the investigation of an accident involving a resident who fell from a ceiling lift during a transfer. The resident involved had severely impaired cognition, disorganized thinking, and physical behavioral symptoms directed toward others, and was dependent on staff for all transfers. During a transfer from bed to wheelchair, the resident fell from the ceiling lift after one of the sling straps became detached, resulting in the resident landing on the floor mat and sustaining a hematoma to the back of the head and a skin tear to the forearm. The incident was witnessed by staff, and it was determined that the sling strap was not fully secured to the lift bar, which led to the fall. Following the incident, the same ceiling lift was used to transfer the resident from the floor to the wheelchair, and then to transfer another resident, before any inspection or removal of the equipment from service. Staff involved in the incident continued to work on the floor and performed additional transfers with the ceiling lift before receiving re-education or competency checks. The facility's policies required that any lift or sling involved in an adverse event be immediately removed from service pending inspection, but this was not followed. Interviews revealed that staff did not double-check the sling loops before lifting, and the competency checklist did not require a double-check of the sling loops prior to lifting the resident. The failure to immediately remove the lift and sling from service and to restrict staff involved in the incident from performing further transfers before retraining resulted in insufficient protection for other residents who required staff assistance with total body lift transfers. The deficiency was substantiated through interviews, document review, and reenactments, which confirmed that the incident occurred as described and that facility policies and procedures were not followed at the time of the event.
Failure to Implement Safe Smoking Interventions
Penalty
Summary
The facility failed to accurately assess and implement safe smoking interventions for a resident with severe cognitive impairment and a history of chronic obstructive pulmonary disease, hypertension, and stroke. The resident was identified as a modified independent smoker, with the facility storing their cigarettes and allowing them to smoke independently. However, observations revealed that the resident was not safely disposing of cigarette ashes, which were falling onto their lap and clothing, resulting in burn-holes in their pants. Despite the resident's smoking assessment indicating they were safe to smoke independently without supervision or a smoking apron, multiple observations showed the resident leaving burning cigarettes unattended and failing to extinguish them properly. Staff interviews revealed that the resident's smoking assessments were conducted by observing through a window rather than directly in the smoking room, and staff were aware of the burn-holes in the resident's clothing but unsure of their duration. The facility's policy required quarterly smoking assessments and interventions based on individualized assessments, yet the assessments inaccurately reported no visible holes in the resident's clothing. The Director of Nursing acknowledged the presence of burn-holes and the need for a new smoking assessment to ensure the resident's safety while smoking, highlighting a deficiency in the facility's implementation of safety interventions for smoking residents.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
The facility failed to ensure professional standards of practice were followed during the administration of insulin to a resident with type two diabetes. The resident, who had intact cognition, was prescribed Semglee insulin to be administered subcutaneously twice daily. During a medication pass, a registered nurse (RN) prepared and administered the insulin without priming the pen as per the manufacturer's instructions. The RN attached a needle to the insulin pen, dialed the dose to 12 units, and administered it to the resident without performing the necessary airshot to remove air bubbles, which is crucial for ensuring the correct dosage. The RN acknowledged the oversight during an interview, confirming awareness of the requirement to prime the insulin pen before administration. The consultant pharmacist and the director of nursing both emphasized the importance of priming the pen to ensure accurate dosing. The facility's policy on medication administration, revised in May 2023, mandates adherence to appropriate standards and protocols, which were not followed in this instance. The manufacturer's package insert for Semglee insulin also specifies the need for an airshot before each injection to remove air bubbles, a step that was omitted in this case.
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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