Auburn Home in Waconia

Inspectors wroteBased on interview and document review, the facility failed to ensure physician-ordered monitoring for potential adverse effects related to antipsychotic medication use was completed when orthostatic blood pressures (BP) were not obtained as ordered for 1 of 3 residents (R7) reviewed for unnecessary psychotropic medication use.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure staff implemented infection prevention and control practices when staff failed to wear required personal protective equipment (PPE), including gowns and gloves, during high-contact resident care activities for 1 of 1 resident (R4) reviewed for enhanced barrier precautions (EBP).

Inspectors wroteBased on interview and document review the facility failed to ensure a physician performed an initial comprehensive assessment within 30 days after admission for 1 of 3 residents (R3), failed to ensure physician visits every 30 days after admission for 90 days for 1 of 3 residents (R3) and failed to ensure physician visits every 60 days after the initial 90 days for 3 of 3 residents (R1, R2, R3).

Inspectors wroteBased on interview and document review, the facility failed to timely update the family member (FM) of a change in condition for 1 of 3 residents (R1) to allow family to be involved in decisions for the resident's end of life care.

Inspectors wroteBased on interview and document review, the facility failed to ensure the comprehensive care plan was updated to include interventions to address constipation and a bowel program for 1 of 3 residents (R1), who had periods of three or four days between documented bowel movements.

Inspectors wroteBased on interview and document review the facility delayed the transfer to the hospital after a change of condition, 1 of 3 residents (R1) who had a change in condition. R1's change of condition was identified at approximately 12:45 a.m. and was sent to the hospital at 3:30.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure resident advance directives were accurately documented to reflect the resident's current wishes which affected 1 of 16 residents (R29) reviewed for advanced directives. This deficient practice resulted in an immediate jeopardy (IJ) for R29 who would have received cardiopulmonary resuscitation (CPR), contrary to their wishes, in the absence of a pulse or respirations. The IJ began on [DATE], when R29's updated physician's order for life sustaining treatment (POLST) signed on [DATE], identified R29's wishes of do not resuscitate (DNR). The three ring household binder and staff report form identified R29's wishes of CPR. The administrator and director of nursing (DON) were notified of the IJ on [DATE], at 3:35 p.m. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure grievance forms and procedures were posted in prominent locations throughout the facility for residents and resident representatives to file grievances, and anonymously if desired for 4 of 4 residents (R18, R16, R19, and R7) reviewed for grievances.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure food items were properly labeled and dated after packaging was opened and were disposed of after the expiration date to prevent cross contamination. In addition, the facility failed to maintain a clean and sanitary kitchen area. This deficient practice had the potential to affect all 32 residents currently residing in the facility. Findings Include: During an initial tour of the kitchen and kitchenettes on 3/31/25 at 2:10 p.m., with dietary manager (DM)-A, the following areas of concern were identified: -walk in refrigerator; one large metal pan of fruit crisp, and a tray of fruit cups were covered and not dated. DM-A indicated they should have been dated and applied dated stickers to each item. -stainless steel cupboards had smears, spots and fingerprints inside and outside the doors. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure appropriate personal protective equipment (PPE) was worn to prevent the spread of infection for for 1 of 4 residents (R25) observed for enhanced barrier precautions (EBP), (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). In addition, the facility failed to ensure safe delivery of beverages during the dining observation. This deficient practice had the potential to affect all 32 residents who resided in the facility. Findings Include: PPE: [...]

Inspectors wroteBased on interview and document review the facility failed to establish a process for antibiotic review in order to determine appropriate indications for use of an antibiotic for 1 of 1 resident (R15) reviewed for antibiotic use.

Inspectors wroteBased on interview and document review, the facility failed to ensure the acting infection preventionist (IP) had completed specialized training in infection prevention and control. This deficient practice had the potential to affect all 32 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to provide timely notification to a provider for change in condition related to falls for 1 of 1 resident (R23) reviewed for falls.

Inspectors wroteBased on interview and document review, the facility failed to report a bruise of unknown origin to the State Agency (SA) for 1 of 1 resident (R23) reviewed for falls.

Inspectors wroteBased on interview and document review, the facility failed to investigate a bruise of unknown origin for 1 of 1 resident (R23) reviewed for falls.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide assistance with routine grooming care which included facial hair removal for 3 of 3 residents (R7, R12, R3) reviewed for activities of daily living (ADLs) who required assistance with grooming and personal hygiene.

Inspectors wroteBased on interview and document review, the facility failed to comprehensively assess and monitor a bruise of unknown origin for 1 of 1 resident (R23) reviewed for falls.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide a comprehensive assessment (fall scene investigation) and a review or adjustment of the current fall prevention interventions to prevent falls for 1 of 1 residents (R23) who had multiple falls within the facility reviewed for falls.

Inspectors wroteBased on interview and document review, the facility failed to identify diagnoses or indications for use of medications for 1 of 6 residents (R15) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure that three years of survey results and the plan of correction were readily accessible to residents or visitors. This deficient practice had the potential to affect all 32 residents currently residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to submit the payroll-based journal system (PBJ) staffing data to Centers for Medicare and Medicaid Services (CMS) as required. This had the potential to affect all 30 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to implement a comprehensive infection control program to include timely surveillance data to identify and prevent the potential spread of communicable disease and infections for 3 of 3 residents (R22, R23, R25) who had identified potential infections. This deficient practice had the potential to affect all 30 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to offer and provide the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine/ boosters and for 3 of 5 residents (R1, R2, R25) reviewed for immunizations.

Inspectors wroteBased on interview and document review, the facility failed to the facility failed to ensure a resident's morning routine preferences were honored for 1 of 1 residents (R26) who voiced concerns about morning routines.

Inspectors wroteBased of observation, interview, and document review, the facility failed to ensure the nursing assistant care plan was revised to reflect updated care planned interventions for 1 of 4 residents (R15) reviewed for falls

Inspectors wroteBased on observation, interview and document review failed to provide oral and toileting/incontinence cares for 1 of 4 residents (R25); and failed to provide timely assistance with toileting/incontinence care for 1 of 4 residents (R15) reviewed for activities of daily living (ADL) and who were dependent on staff for ADL's

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure interventsion for preventing pressure ulcers were implemented for 1 of 2 residents (R25) reviewed who was at risk for the development of pressure ulcers.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure residents were appropriately supervised to prevent falls for 1 of 2 (R15) resident reviewed for falls. In addition, the facility failed to ensure care planned fall interventions were utilized for 1 of 2 residents (R25) reviewed for falls.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure adequate catheter care for 1 of 1 (R26) residents reviewed for catheter cares.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure post-dialysis access site monitoring was consistently completed to provide continuity of care and reduce the risk of complication (i.e., bleeding, clotting) for 1 of 1 residents (R6) reviewed for dialysis care.