The Villas at Osseo LLC

Inspectors wroteBased on interview, and record review the facility failed to ensure residents were free from resident to resident abuse for 5 of 5 residents (R3, R5, R6, R7, & R8) reviewed when R1 had physically assaulted R3 and R5 and verbally assaulted all five residents resulting mental anguish and multiple police visits.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a clean comfortable homelike environment for 1 of 3 residents (R4) reviewed for home like environment.

Inspectors wroteBased on interview and record review the facility failed to develop the care plan for 1 of 1 resident (R1) review for care plan. R1 was placed on 1:1 staff supervision with specific interventions that were not on added to his care plan.

Inspectors wroteBased on interview and document review, the facility failed to notify the physician and or the resident representative timely for 2 of 3 residents (R1,R4) reviewed for change in condition.

Inspectors wroteBased on interview and document review the facility failed to provide pain management in accordance with the resident's new physician's orders to a resident experiencing pain for 1 of 3 residents (R1) reviewed for medication administration.

Inspectors wroteBased on interview and record review, the facility failed to timely transcribe the physician's new orders to initiate a pain management therapy for 1 of 3 residents (R1) reviewed for medication administration.

Inspectors wroteBased on interview and document review the facility failed to ensure non-pharmacological (non-pharm) interventions were attempted/offered and documented prior to the administration of as needed (PRN) narcotic medications for 1 of 3 residents (R3) reviewed for pain.

Inspectors wroteBased on interview and document review, the facility failed to accurately transcribed a physician order with a start date for 1 of 3 (R2) residents reviewed for medication administration.

Inspectors wroteBased on record review and interview the facility failed to conduct care conferences on a quarterly basis for 6 of 6 residents (R12, R14, R26, R27, R56, R70) reviewed for care planning. Additionally, the facility failed to update the care plan for 1 of 6 residents (R70) reviewed for communication and language preferences.

Inspectors wroteBased on observation and interview, the facility failed to ensure dignity was maintained for 1 of 1 residents (R65) reviewed for dignity related to dressing. Findings Include: R65's admission minimum data set (MDS) dated [DATE], indicated R65 was admitted on [DATE], was able to communicate clearly and understand others, was cognitively intact, and had the following diagnoses: bilateral (both sides) below the knee amputation, HTN, wound infection, diabetes, malnutrition, anxiety, depression, and asthma. On 6/9/25 at 3:14 p.m , R65 was observed sitting in bed wearing only a black and tan sweater, tan grippy socks over R65's bilateral stumps, and a brief. R65 stated he should have been wearing pants, but staff didn't complete the task. F65 was upset and stated, how can you treat an elderly person this way?. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure proper cleaning of wheelchairs for 2 of 2 residents (R14, R13) reviewed for dignity. Findings Include: R14's quarterly MDS dated [DATE], included R14 was cognitively intact. R14 utilized a wheelchair for mobility and required partial to moderate assistance for personal hygiene. R14 had diagnoses of arthritis, abnormalities of the gait or mobility, and essential tremor. On interview on 6/10/25 at 9:22 a.m., R14 commented on the condition of her wheelchair. R14 stated the wheels were worn out and had gouges and divots out of them which caused the wheelchair to be difficult to be maneuvered by transportation company. R14 also stated the arm rests were missing chucks of covering black covering. R14 stated it had been years since her wheelchair was cleaned and had dirt on it. [...]

Inspectors wroteBased on observation, interview, and document review the facility failed to provide assistance with grooming for 1 of 2 resident (R145) reviewed for activities of daily living (ADL's).

Inspectors wroteBased on observation and interview the facility failed to ensure medications were secured in resident accessible areas. In addition, the facility failed to ensure medications were labeled with current physician-ordered administration instructions including medication name, and resident name. This unsafe practice had the potential to impact residents who received medications from the 100-unit medication cart.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Quality Assurance Assessment and Performance Improvement Plan (QAPI) committee effectively sustained ongoing compliance related to repeat citations from past surveys regarding dignity, which was also identified during this survey. This had the potential to affect all 85 residents in the facility.

Inspectors wroteBased on observation and interview, the facility failed to complete proper hand hygiene during 2 of 3 dining observations. This had the potential to affect all 85 residents.

Inspectors wroteBased on interview, and document review the facility failed to ensure 3 of 5 residents (R12, R61, and R65) were offered, educated on, and provided the pneumococcal vaccination series as recommended by the Centers for Disease Control (CDC), who were reviewed for immunizations.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure staff followed five rights of medication administration for 1 of 3 residents (R1) reviewed for significant medication errors. R1 received five times the prescribed dose of Methadone for three days (nine shifts) which impaired her speech, ability to verbalize needs and consume nutrition. This resulted in an immediate jeopardy (IJ) for R1. The IJ began on 4/26/25, when the facility staff administrating R1's medication failed to compare the written order on the Medication Administration Record (MAR) with the prescription label on the physical bottle of Methadone before administration which resulted in R1 receiving five times the prescribed dose of Methadone nine times over the course of three days. The IJ was identified on 5/7/25, and the administrator was notified of the IJ on 5/7/25 at 1:45 p.m. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to notify resident representative timely following resident change of condition for 1 of 1 residents (R2) who had a weight loss of eight pounds in 27 days.

Inspectors wroteBased on interview and document review the facility failed to comprehensively assess and implement appropriate pain monitoring to ensure comfort for 1 of 1 residents (R1) reviewed for pain management and whom was non-verbal and unable to communicate their needs.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure side rails were comprehensively assessed to determine if they were appropriate and safe, discuss the risks and benefits, and obtain informed consent prior to use of bed rails for 2 of 3 residents (R2, R3) who were observed to have side rails raised on their beds.

Inspectors wroteBased on observation, interview and document review, the facility failed to protect one of one residents (R4) from abuse and neglect when R4 was deprived of her care planned bed mobility and transfer needs, while she voiced pain and signs of distress, visibly struggled with these movement activities, and was placed in apparent unsafe laying and seated positions. These actions resulted in a fall for R4 where she sustained a distal femur fracture that required hospitalization and surgical intervention. The facility implemented corrective action based on their investigation and so the deficient practice was issued at an immediate jeopardy (IJ) past non-compliance. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure adequate supervision to prevent an elopement (leaves premises or a safe area without authorization or necessary supervision) were provided to 1 of 3 residents (R1), who was at risk for elopement, utilized a wanderguard (elopement signaling device), and who had history of independent wanderguard removal. This resulted in immediate jeopardy (IJ) for R1 when she left the facility without staff knowledge and was outside for approximately 30 minutes exposed to lower temperature weather and unsafe conditions. The facility implemented corrective action based on their investigation and so the deficient practice was issued at IJ, past non-compliance. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to communicate in a dignified manner to 1 of 1 residents (R2) reviewed for dignity.

Inspectors wroteBased on interview and document review, the facility failed to notify resident representative timely following resident falls with injury for 1 of 1 residents (R3) who had been hospitalized twice from falls, one with hip fracture and then a neck fracture.

Inspectors wroteBased on observation, interview and document review, the facility failed to complete the initial comprehensive assessment using direct observation and communication with the resident for 1 of 1 resident (R3) reviewed for falls.

Inspectors wroteBased on interview, observation and document review, the facility failed to update the care plan with identified fall interventions for 1 of 3 residents (R3) reviewed for falls.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide medication as ordered by the physician for 3 of 3 residents (R1, R2, R3) reviewed for pharmacy services.

Inspectors wroteBased on observation, interview and document review, the facility failed to maintain infection control practices while conducting blood glucose checks for 2 of 4 patients (R1, R4) reviewed for medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to utilize professional interpretive services for 1 of 1 residents (R66) reviewed for oral communication.

Inspectors wroteBased on document review, and interview the facility failed to ensure a written notification of transfer and/or discharge was sent to the office of the Ombudsman for 1 of 4 (R30) reviewed for hospitalization and/or discharge.

Inspectors wroteBased on interview and document review, the facility failed to ensure a level II preadmission screening and resident review (PASARR) was completed for 1 of 1 residents (R25) residents reviewed with a serious mental illness diagnosis.

Inspectors wroteBased on observation, interview and document review, facility failed implement interventions to prevent further development of decreased range of motion and ability for 2 of 2 residents (R17, R51) reviewed for positioning and mobility.

Inspectors wroteBased on document review and interview the facility failed to report to the State Agency (SA) a injury of a hematoma on right leg for 1 of 1 (R1) when reviewed for injury of unknown origin.

Inspectors wroteBased on interview and document review the facility failed to thoroughly investigate an injury of unknown origin (hematoma on right leg) for 1 of 1 resident (R1) reviewed for abuse.

Inspectors wroteBased on interview and document review, the facility failed to allow a resident/resident's legal representative to participate in treatment decisions for 1 of 1 resident (R1) who was on hospice, had a seizure and was initially denied access to medical treatment at a hospital.

Inspectors wroteBased on interview and document review, the facility failed to ensure a potential allegation of neglect was recognized and reported to the State agency (SA) in a timely manner for 1 of 1 resident (R1) reviewed.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure medications were administered in accordance with physician orders for 10 of 10 residents (R2, R5, R7, R10, R11, R13, R16, R19, R20, R21) who were provided medications outside of ordered parameters by three staff on three separate units.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure insulin (blood sugar regulator) medication was administered in accordance with physician orders for 4 of 4 residents (R9, R15, R18, R20) who were provided insulin outside of ordered parameters and manufacturer recommendations by two staff on two separate units.

Inspectors wroteBased on observation, interview, and document review the facility failed to implement comprehensive care plans for 1 of 1 residents (R1) reviewed for toileting and falls.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure safe transfers to prevent or mitigate the risk of falls and/or injury for 2 of 4 residents (R4, R1) reviewed for falls.

Inspectors wroteBased on interview and document review, the facility failed to ensure the therapeutic recreational director TRD-(A) was trained or had demonstrated competency prior to assisting residents with transfers, locomotion on/off unit, dressing, and ambulation for 1 of 1 residents (R4) reviewed for falls.

Inspectors wroteBased on observation and interview, the facility failed to properly label and date food items removed from their original boxes, rotate food items prior to their expiration date, and reduce the risk of physical contamination of food related to poor personal hand hygiene which had potential to affect all 79 residents.

Inspectors wroteBased on interview and document review, the facility failed to ensure a preadmission screening and resident assessment and review (PASARR) level 2 had been completed for 1 of 1 resident (R22) reviewed for PASARR level 2.

Inspectors wroteBased on interview and document review the facility failed to revised and update comprehensive care plan and assessments for 1 of 3 resident (R21) reviewed for comprehensive care plans.

Inspectors wroteBased on observation, interview, and document review, the facility failed to follow physician orders, document for proper positioning and use of assistive devices for 1 of 3 residents (R1) reviewed for assessment. R1's Annual Minimal Data Set (MDS) dated [DATE], indicated intact cognition (able to fully understand). Diagnoses of other neurological conditions (Issues with brain and spine) cerebral palsy (difficulty controlling muscles), and schizophrenia (twisted sense of reality). R1 was totally dependent of cares with impaired range of motion to both upper extremities (arms). [...]

Inspectors wroteBased on interview and document review the facility failed to have a current treatment order for 1 of 1 resident (R21) reviewed for physician orders.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure an appropriate medical diagnosis for use of scheduled anti-psychotropic medications for 1 of 3 residents (R33) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review the facility failed to submit complete and accurate direct care staffing information, including information for agency and contract staff, during 1 of 1 quarters (Quarter 2), reviewed for payroll based journal (PBJ).