Mn Veterans Home-Mpls

Inspectors wroteBased on observation, interview, and document review the facility failed to monitor dishwasher temperatures in the main kitchen. This had the potential to increase the risk of food borne illness and affect 293 residents who received food from dietary services.

Inspectors wroteBased on interview and document review, the facility failed to ensure as-needed (PRN) psychotropic medication orders had a defined stop date and were limited to 14 days without a documented rationale for extension for 1 of 5 residents (R279) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and document review the facility failed to follow doctor's orders for 1 of 1 resident (R87) reviewed who required daily weights. In addition, the facility failed to ensure services were coordinated with the hospice agency for 1 of 1 resident (R265) reviewed who received hospice services.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure enhanced barrier precautions (EBP) were followed for 1 of 1 resident (R11) reviewed for EBP.

Inspectors wroteBased on interview and document review, the facility failed to ensure that recommended pneumococcal vaccinations were offered and/or that shared clinical decision-making regarding pneumococcal vaccinations occurred, as outlined by the Centers for Disease Control (CDC), to reduce the risk of severe disease for 1 of 5 residents (R11) reviewed for immunizations.

Inspectors wroteBased on observations, interview and document review, the facility failed to follow R1's Physician Orders for Life-Sustaining Treatment (POLST) do not attempt resuscitation (DNR), do not intubate, and to allow natural death for 1 of 3 residents (R1) when R1 became unresponsive after a fall and licensed practical nurse (LPN)-A initiated cardiopulmonary resuscitation (CPR). The immediate jeopardy began on [DATE] when R1 became unresponsive after a fall, licensed practical nurse (LPN)-A initiated cardiopulmonary resuscitation (CPR), and was identified on [DATE]. The campus administrator, director of nursing, and nurse manager of facility staff were notified of the immediate jeopardy at 3:20 p.m. on [DATE]. The immediate jeopardy was removed on [DATE] and the deficient practice corrected on [DATE], prior to the start of the survey and was therefore Past Noncompliance.

Inspectors wroteBased on interview and document review, the facility failed to ensure a facility closure policy and procedure had been developed. This had the potential to effect all residents residing in the building.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident was free from a significant medication error for 1 of 3 residents (R1) reviewed for medication errors. This resulted in an Immediate Jeopardy (IJ) citation when licensed practical nurse, (LPN)-A administered morphine, a narcotic medication, 20 times the amount that was ordered by the provider. The immediate jeopardy began on 4/11/25 p.m. when LPN-A administered 20 times the amount of liquid morphine to R1 and was identified on 4/17/25. The director or nursing (DON) and the Administrator were notified of the immediate jeopardy at 3:03 p.m. on 4/17/25. The immediate jeopardy was removed on 4/17/25, and the deficient practice corrected on 4/14/25, prior to the start of the survey and was therefore was issued at past noncompliance.

Inspectors wroteBased on interview and document review, the facility failed to ensure a voiced grievance of a missing shirt was acted upon timely to help facilitate prompt resolution for 1 of 1 resident (R232) who reported such item as missing with no follow-up.

Inspectors wroteBased on interview and document review, the facility failed to conduct accurate and on-going assessments for bruising, and implement skin protection interventions for 1 of 1 resident (R10) reviewed for anticoagulant use, and failed to follow orders for ankle compression sleeves (compression stockings) to legs for 1 of 1 resident (R53) reviewed for edema.

Inspectors wroteBased on interview and document review, the facility failed to follow up and implement treatment for improved hearing for 1 of 1 residents (R277) when complaints of hearing loss were made.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure staff assisted 1 of 1 resident (R74), who was reviewed for restorative nursing program, to attend their GI (general term used for government issued) therapy gym sessions or document reasons resident was not available for attendance. The facility further failed to ensure occupational therapist recommendations were care planned and initiated for one of two residents (R184) who was assessed as at risk for bilateral hand contractures and impaired skin due to clenching fist reviewed for services to prevent decrease in range of motion.

Inspectors wroteBased on observation, interview, and document review, the facility failed to analyze and care plan R596's multiple declinations to wear supplemental oxygen as ordered for 1 of 1 resident (R596) reviewed for oxygen use.

Inspectors wroteBased on observations, interview, and document review, the facility failed to ensure staff were competent to apply medicated ointment for 1 of 1 resident (R232) reviewed for self-administration.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure enhanced barrier precautions (EBP) were utilized appropriately for 2 of 2 residents (R269, R595) reviewed for EBP related to wounds. In addition, staff failed to perform appropriate hand hygiene for 1 of 1 resident (R595) observed to receive cares in enhanced barrier precautions.

Inspectors wroteBased on observation, interview, and document review the facility failed to assess a resident for the ability to self-administer medications via a nebulizer (machine that aerosolizes medications for inhalation) for 1 of 1 residents (R49) reviewed for self-administration of medications.

Inspectors wroteBased on observation, interview and record review the facility failed to comprehensively assess residents food preferences and ensure meal choices were provided for 1 of 1 residents (R146) reviewed for choices.

Inspectors wroteBased on interview and document review, the facility failed to ensure a voiced grievance of a missing electric toothbrush was acted upon timely to help facilitate prompt resolution for 1 of 1 resident (R187) who reported such item as missing with no follow-up.

Inspectors wroteBased on interview and document review, the facility failed to ensure assessed and care-planned interventions for skin monitoring were consistently implemented to reduce the risk of complication (i.e., infection, breakdown) for 1 of 3 residents (R246) reviewed for non-pressure skin impairments.

Inspectors wroteBased on interview and document review the facility failed to comprehensively assess and develop a program to maintain bowel continence was implemented for 1 of 1 residents (R146) reviewed for bowel management.

Inspectors wroteBased on interview and document review, the facility failed to ensure a provider order for a throat culture had been obtained in a timely manner for 1 of 1 residents (R124) reviewed for infection.

Inspectors wroteBased on interview and document review, the facility failed to ensure recommended pneumococcal vaccinations, as outlined by the Centers for Disease Control (CDC), were offered and/or provided to reduce the risk of severe disease for 1 of 5 residents (R148) reviewed for immunizations. In addition, the facility failed to ensure 5 of 5 residents (R24, R48, R49, R148, R243) medical records included documentation that the resident or resident representative was provided education regarding influenza immunization benefits and potential side effects.