Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Benedictine Health Center Of Minneapolis during CMS and state inspections, most recent first.
Facility staff failed to manage a scabies outbreak affecting multiple residents and did not consistently follow TBP. Two residents with itching and rashes were treated with ivermectin, but their care plans lacked clear scabies precautions, and staff gave inconsistent accounts of outbreak tracking, contact tracing, and resident/staff education. In addition, staff did not reliably use gowns and gloves for a resident on contact precautions or for residents requiring EBP during hands-on care and suctioning.
Dusty room fans were found in multiple resident rooms, including rooms of residents with trachs, vents, and tube feedings. Surveyors observed dust on fan grids and blades while residents were in bed or sleeping, and one resident said the fan was dirty and did not know when it was cleaned. Staff confirmed the fans were dusty and said they should be cleaned, especially in rooms with respiratory problems.
A resident with severe cognitive impairment and a seizure disorder was prescribed Keppra 1000 mg BID after a hospital transfer, but the order was transcribed as 100 mg BID and the resident received the lower dose for weeks. During that time, the resident had repeated seizure activity and was sent to the ER more than once. Staff later identified the transcription error, but the facility did not report the significant medication error to the SA within 24 hours.
Failure to Provide Bed Hold Notice: A resident with moderately impaired cognition was sent to the hospital after not responding well and later returned after several days. The chart showed notification of the spouse, supervisor, and on-call provider, but there was no documentation that a bed hold notice was completed before transfer or provided afterward, and staff could not locate a signed or uploaded form.
Incorrect Discharge MDS Coding: A resident admitted after left knee joint replacement received therapy and was discharged home, but the discharge MDS incorrectly coded the discharge destination as a short-term general hospital. The EMR and discharge plan of care both documented that the resident returned home with sister transportation, home health services arranged, and prescriptions sent to a local pharmacy. The CMDS verified the coding error.
The facility failed to keep care plans accurate for two residents being treated for scabies and one resident with multiple pressure areas. Two residents had ivermectin orders and isolation signage, but their records did not document scabies or the correct precautions, and staff confirmed they were being treated for scabies. Another resident had multiple wounds and pressure areas with updated treatment orders, but the skin care plan was not revised to match the current condition or wound care needs.
A resident with severe neurologic and respiratory conditions had Eliquis held after hematuria was noted, but the facility did not document ongoing bleeding monitoring or promptly clarify the hold order with the NP to reinstate the anticoagulant. The facility also delayed follow-up on urine testing: a specimen was mislabeled, the repeat culture later grew E. coli and Proteus mirabilis, and staff did not promptly notify the provider or obtain antibiotic orders despite available lab results.
A facility failed to monitor orthostatic BP for two residents receiving antipsychotic medications who also had fall histories. One resident had lurasidone and risperidone orders, reported dizziness, and had multiple falls; the other had a clozapine order and a recent major-injury fall. The EMR lacked evidence of orthostatic BP monitoring for either resident, and the clinical manager/RN confirmed there were no care planned or ordered interventions to monitor it.
The facility failed to secure residents' PHI, leaving care sheets with sensitive information unattended in various areas. Staff acknowledged the oversight, confirming the presence of private information on these sheets, which should have been kept out of sight to protect resident privacy.
A facility failed to ensure a resident and their representative participated in care conferences for care planning. The resident, with severe cognitive impairment and multiple diagnoses, did not have a care conference conducted after a significant change in status. Staff interviews revealed that the care conference was overdue, and the family member confirmed no recent invitations to participate. This lapse violated the facility's policy on resident involvement in care planning.
A facility failed to update a resident's care plan to include a foley catheter placed during hospitalization and anxiety interventions from a psychology provider. The resident's care plan and work sheets lacked necessary updates, leading to staff being unaware of the resident's current needs. Interviews confirmed the absence of catheter-related information in the EMR, and the deficiency was attributed to a lack of real-time updates and communication among the care team.
The facility failed to provide adequate personal hygiene and self-care for residents dependent on staff, leading to deficiencies in maintaining a dignified appearance and reducing the risk of complications. A resident with severe cognitive impairment was observed with long, soiled fingernails, while another resident with significant cognitive impairment had long, jagged toenails and fingernails. A third resident, with moderate cognitive impairment, was not consistently shaved despite expressing a preference to be clean-shaven. Staff interviews revealed inconsistencies in care documentation and communication, and family members expressed concerns about the lack of basic care.
A facility failed to provide care-planned activities for a non-verbal resident with severe cognitive impairment. Despite having a care plan that included listening to music and watching TV, the resident was often left in a silent room. Staff interviews revealed poor communication and coordination between nursing and activities staff, resulting in minimal engagement with the resident. The therapeutic recreation director confirmed that the television should be on for the resident, but this was not consistently done.
A facility failed to ensure proper flushing of a gastrostomy tube for a resident with severe cognitive impairment and multiple medical conditions. The RN did not measure the prescribed 150 ml of water for flushing after administering medications, potentially leaving residual medication in the tube. Interviews with staff confirmed the deviation from expected procedures, and the facility's policy on flushing was not provided.
The facility failed to provide comprehensive pain management for two residents. One resident, who was non-verbal, showed signs of potential pain, but the facility did not conduct thorough assessments or implement consistent monitoring. Another resident, with multiple fractures, did not receive non-pharmacological interventions, and pain medication administration lacked proper documentation. Staff interviews revealed inconsistencies in pain assessment and documentation practices.
A facility failed to reassess the safety and appropriate use of bed rails for a resident with impaired cognition. Despite the resident's declining condition and increased need for assistance, the facility did not conduct updated assessments since September 2022. Interviews with staff revealed a lack of awareness and process for ongoing monitoring or reassessment of side rail use, and the facility's policy did not specify when ongoing assessments should be completed.
A facility failed to monitor the efficacy of antipsychotic medication for a resident with severe cognitive impairment. The resident was on Seroquel for psychosis and major depressive disorder, but staff did not track specific target behaviors. Interviews revealed uncertainty about the resident's symptoms, and the care plan lacked details on behaviors to monitor. The facility's policy required identifying and monitoring target behaviors, which was not followed.
A facility failed to follow proper infection control practices during tracheostomy care for a resident on enhanced barrier precautions. An RN did not change gloves between administering medications through a gastrostomy tube and performing tracheostomy care, contrary to CDC guidelines and facility policy. Interviews with staff confirmed the oversight, highlighting a lapse in infection prevention measures.
The facility failed to respond promptly to ventilator alarms for three residents who were ventilator-dependent and severely cognitively impaired. Alarms were not addressed in a timely manner, with delays ranging from several minutes to nearly half an hour. Staff acknowledged the importance of prompt responses but admitted that responses depended on staffing levels. The facility lacked a clear policy on ventilator alarm response times.
A facility failed to properly monitor and manage pressure ulcers for four residents, leading to deficiencies in care. One resident developed an unstageable sacral ulcer that was not treated timely, resulting in hospitalization. Another resident with multiple ulcers had inadequate documentation and improper wound care practices, including lack of hand hygiene and use of inappropriate materials. Similar issues were observed in two other residents, highlighting failures in wound care protocols and infection control.
A resident with a history of respiratory failure and septicemia was found with a heart rate of 156 bpm, but the nurse on duty did not notify a provider. The resident was later found unresponsive and died despite CPR efforts. The facility failed to follow standing orders and policies requiring provider notification for significant changes in condition.
A resident with multiple medical conditions, including quadriplegia and respiratory failure, was admitted with a stage 2 pressure ulcer. The facility failed to comprehensively assess and treat the ulcer, resulting in the development of a new pressure injury. Additionally, the lack of management and assessment of a cervical collar led to a pressure ulcer on the resident's head, discovered only after hospital transfer. Staff interviews revealed confusion and lack of communication regarding wound care and collar management.
A resident with cognitive impairments posted on social media about alleged abuse by facility staff, but the LTC facility failed to report the suspicion to the State Agency within the required timeframe. Despite awareness of the posts by the administrator and DON, the facility did not act promptly, violating their abuse prevention policy.
A resident with severe cognitive impairments alleged abuse by facility staff through social media posts. The facility's investigation was incomplete, lacking proper documentation and adherence to policy. A skin assessment showed no injuries, and plans for a room camera were not executed due to lack of consent. Interviews with other residents and staff were insufficiently documented.
The facility failed to implement enhanced barrier precautions (EBPs) for two residents with tracheostomies, ventilators, and indwelling urinary catheters. Care plans did not address infection risks or PPE use, and staff performed care tasks without gowns. Interviews revealed a lack of awareness about EBPs among staff, despite facility policy requiring them for residents with indwelling medical devices.
Scabies outbreak not properly managed and transmission precautions not followed
Penalty
Summary
The facility failed to properly manage a potential scabies outbreak involving residents on the 4th floor and 2nd floor, with chart documentation showing 14 residents on the 4th floor and 2 residents on the 2nd floor diagnosed with scabies in the chart dated 1/29/26. Two residents reviewed, R73 and R15, were later prescribed ivermectin for scabies treatment, but their care plans printed in April lacked evidence that they were being treated for possible scabies infection or placed on transmission-based precautions. R73’s record showed he was dependent on staff for most ADLs, and during observation he reported itching for weeks and said he had only recently started taking a pill to help with the itching. R15’s record showed he was also dependent on staff for most ADLs, and his family member reported he had been itching for weeks with worsening scratching and visible marks on his chest and buttocks. Facility staff and leadership gave inconsistent accounts of the outbreak and the response to it. The infection preventionist stated the medical director diagnosed scabies in January and that residents with rashes were treated as if they had scabies, but she was unsure whether contact tracing had been completed for residents discharged within 6 weeks of the first outbreak and could not provide documentation showing it was done. She also stated she was unaware that the two current residents had only received one of two ivermectin doses and was not involved in education for current staff regarding the new cases. The nurse manager confirmed that R15 and R73 were being treated for scabies and that R73 should have been on contact precautions, not enhanced barrier precautions, and also confirmed there had been a scabies outbreak on the 4th and 2nd floors. The administrator stated the outbreak at the end of January was mostly on the 2nd floor and that the 4th floor had only one treated case. The facility also failed to ensure transmission-based precautions were followed for residents requiring enhanced barrier precautions and contact precautions. R24’s care plan identified enhanced barrier precautions for respiratory failure, tracheostomy, and gastrostomy tube, and also identified scabies on the left hand and arm with a start date of 1/29/26, but the care plan did not direct staff to follow contact precautions. During observation, a contact precautions sign on the door instructed staff to wear a gown and gloves before entering, yet a nursing assistant repositioned R24 without a gown and a nurse entered the room to obtain vital signs without a gown. R45’s care plan directed staff to use infection control principles and enhanced barrier precautions, and during observation a nurse suctioned him without wearing a gown. Staff stated they knew gowns were required in some situations but did not consistently follow the posted precautions or demonstrate understanding of when PPE was required.
Dusty room fans in respiratory care rooms
Penalty
Summary
The facility failed to keep fans in resident rooms clean for 7 of 24 residents, including residents with tracheostomies and/or ventilators. During observations, wall-mounted fans in the rooms of residents with significant respiratory needs were seen with dust accumulated on the grids and, in several rooms, on the fan blades when the fans were stopped. The affected residents included individuals who were unable to speak or were nonverbal, had impaired decision making or were dependent on staff for all ADLs, and had diagnoses such as cardiorespiratory debility, chronic respiratory failure, amyotrophic lateral sclerosis, progressive neurological condition, COPD, dysphagia, and dependence on ventilator, tracheostomy, oxygen, suctioning, and tube feeding. Resident observations showed the fans were present and operating in rooms where residents were in bed with tracheostomies, ventilators, and tube feedings. One resident stated the fan was dusty and said housekeeping cleaned the fan, but not very often. Another resident stated the fan was dirty and was unsure when or who cleaned it. Surveyors observed dust on the fan grids and blades in multiple rooms, including rooms where residents were sleeping, lying in bed, or not responding to questions. During interviews, an RN verified the fans were dusty and stated they should be cleaned to prevent allergies and/or infections, especially in rooms with residents with respiratory problems. Another RN stated fans in resident rooms should be cleaned to prevent dust blowing into the room, especially for residents with tracheostomies and ventilators. A housekeeper aide stated he cleaned the fans once a week, while the maintenance director stated he was not sure whether fans were included on the cleaning template and said his expectation would be to check the fans every week and clean them at least monthly. The facility procedure for resident room routine cleaning required maintaining clean and attractive surroundings, and the room survey form included fans as part of the room environment to be observed for cleanliness and function.
Failure to Report Significant Medication Error
Penalty
Summary
The facility failed to ensure a significant medication error was reported to the State Agency within 24 hours for one resident who was prescribed seizure medication. The resident had severe cognitive impairment, depended on staff for all activities of daily living, and had diagnoses including hemiplegia and hemiparesis following cerebral infarction, hypertension, diabetes, non-Alzheimer's dementia, seizures, and depression. After a seizure episode on 10/20/25, the resident was sent to the hospital and returned with an order for levetiracetam (Keppra) 1000 mg twice daily. The resident's medication administration record showed the order was transcribed incorrectly as levetiracetam 100 mg twice daily, and the resident received the lower dose from 10/21/25 through 11/13/25. During that period, the resident had additional seizure activity, including a 60-second jerking seizure on 10/31/25 and violent recurrent seizures on 11/13/25 that required transfer to the ER. The hospital summary noted negative lab work for infection and an elevated lactate level that may have been consistent with the seizure episode. A customer concern form and event report identified the issue as a medication error involving the wrong dose being given, and the event report listed the error as occurring from 10/20/25 through 11/14/25. Interviews showed the HUC transcribed orders into the computer and nurses verified them, and the nurse manager stated the transcription error resulted in the resident receiving 100 mg instead of 1000 mg twice daily. The administrator and regional nurse stated the transcription error was not reported because it was not clear it caused harm, and the error was handled internally.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to provide a bed hold notice for one resident who was hospitalized and returned to the facility. The resident had moderately impaired cognition on the quarterly MDS assessment, with no hallucinations, delusions, or behaviors noted. The resident was sent to the hospital for not responding well, and the record shows the spouse, supervisor, and on-call provider were notified. The resident remained in the hospital from 2/22/26 through 2/27/26, but the progress notes did not show that a bed hold was completed before transfer or that a bed hold was sent after the transfer. Review of the resident’s medical record found no evidence that a bed hold notice was provided for the hospitalization in either the electronic record or the paper chart. Staff interviews indicated the expected process was for nursing staff to obtain the bed hold when the resident transferred to the hospital, have the form signed if possible, and upload it to the electronic medical record. The ADON and RN staff were unable to locate a completed bed hold for the resident’s hospitalization, and the administrator stated there was no further documentation available.
Incorrect Discharge MDS Coding
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one resident, R88, on discharge. R88 was admitted with a diagnosis of aftercare following left knee joint replacement, received therapy services during the stay, and was discharged from the facility to her home. However, the discharge MDS dated [DATE] indicated that R88 was discharged to a short-term general hospital. The electronic medical record included a progress note dated 2/9/26 at 3:33 p.m. stating that R88 was discharged at 11:00 a.m. to her home with her sister providing transportation, that a local home health agency would provide services, and that medication prescriptions were faxed to a local pharmacy. The discharge plan of care also indicated that R88 returned home on 2/9/26. During interview, the corporate MDS/registered nurse verified that the discharge MDS incorrectly coded the discharge destination as a hospital and stated that the facility's MDS nurse made a coding error.
Incomplete scabies documentation and outdated skin care plan
Penalty
Summary
The facility failed to ensure that residents on transmission-based precautions for possible scabies had a documented diagnosis and care plan that accurately reflected their condition. Two residents, both dependent on staff for most activities of daily living, had orders for ivermectin for dermatitis, but their records did not show that they were being treated for scabies or that they were on contact precautions. One resident stated he had been itching for weeks and had recently started taking a pill to help the itching, and a sign on his door directed staff to use enhanced barrier precautions. During interview, nursing staff confirmed both residents were being treated for scabies, not dermatitis, and stated one resident should have been on contact precautions rather than enhanced barrier precautions. Infection control staff stated that having a medical record showing treatment for scabies would be important if a symptomatic resident discharged or needed a higher level of care. The facility also failed to keep one resident’s skin care plan accurate and updated to reflect current pressure areas and wound care needs. The resident was unable to talk, dependent on staff for all ADLs, and had multiple skin problems including pressure areas, open lesions, and pressure-reducing devices in use. His active orders included wound care for pressure areas on the left lateral distal leg, left lateral proximal leg, left heel, left ear, and under the left side where trach ties were secured, along with weekly skin checks and other skin-related treatments. However, the care plan’s skin integrity problem, goal, and interventions had not been revised to match the resident’s ongoing and changing skin conditions. Record review showed the skin care plan still referenced older pressure areas and had not been updated to include the resident’s later wounds and revised wound care orders. Although wound care reports documented stage 2 pressure areas at multiple sites and skin assessments were completed, the care plan remained last revised months earlier and did not reflect the resident’s current skin status. Nursing staff confirmed that care plans were expected to be accurate and reflect residents’ problems, goals, and interventions, and that the plan had not been updated despite changes in the resident’s wounds and treatment orders.
Delayed bleeding monitoring and lab follow-up for anticoagulant hold and UTI
Penalty
Summary
The facility failed to monitor for signs and symptoms of bleeding and failed to follow up with the provider to reinstate an anticoagulant for a resident who was comatose, dependent on staff for activities of daily living, receiving tube feeding, oxygen, tracheostomy care, oral suctioning, and gastrostomy tube care. The resident had diagnoses including stroke, atrial fibrillation, heart failure, hypertension, nontraumatic intracerebral hemorrhage, acute and chronic respiratory failure, persistent vegetative state, autonomic dysreflexia, and unspecified convulsions. The resident received Eliquis twice daily until the morning dose on 3/9/26, when dark red urine was noted and the on-call NP was contacted. The on-call NP directed staff to continue monitoring and to continue Eliquis due to clotting risk, and later that day the resident’s NP was updated and held the Eliquis. After the anticoagulant was held, documentation showed ongoing blood in the urine, but the record lacked documentation of continued bleeding monitoring after 3/10/26. The EMR also showed that the order was treated as held/discontinued because the computer system discontinued medications placed on hold, and the facility did not clarify the hold order. The resident’s family member reported that blood in the urine was first observed and reported to nursing, that no further bleeding was seen after that point, and that on a later visit the Eliquis had still been on hold until the family member asked staff to contact the NP to restart it. The ADON confirmed the lack of documentation for further bleeding monitoring and stated the facility failed to clarify the hold order. The facility also failed to obtain laboratory results and update the primary provider in a timely manner to initiate treatment for a urinary infection. A urine sample was collected after dark red urine was noted, but the first specimen was cancelled by the laboratory because the resident’s name was misspelled. A second specimen was collected and sent, and the urinalysis was reviewed with the NP, who instructed staff to wait for culture results because the nitrate result was negative. The culture later showed growth of more than 100,000 CFU/ml Escherichia coli and more than 100,000 CFU/ml Proteus mirabilis, but the progress notes lacked documentation of culture follow-up or provider contact for antibiotic orders, and the MAR did not show an antibiotic. Interviews with the family member and facility staff confirmed that the culture results were available before the provider was contacted and that the delay in follow-up occurred despite the facility’s expectation that lab results be reviewed and reported promptly.
Failure to Monitor Orthostatic Blood Pressure for Residents on Antipsychotics
Penalty
Summary
The facility failed to monitor orthostatic blood pressure for 2 residents who were receiving antipsychotic medications and had histories of falls. A NIH article cited in the report stated that elderly residents are at risk for adverse effects from antipsychotic medications, including orthostatic hypotension, which can lead to dizziness, syncope, and falls, and that it should be evaluated by history and measurement. The facility policy on psychotropic medication use also identified orthostatic blood pressure as a medication side effect to be monitored. One resident was cognitively intact and independent with most ADLs, had orders for lurasidone and risperidone, and the EMR lacked evidence that orthostatic blood pressure was being monitored. The resident had multiple falls and reported feeling dizzy at times, including an episode where staff found the resident sitting on the bathroom floor after lowering herself there بسبب dizziness. Another resident was cognitively intact, dependent on staff for most ADLs, and had an order for clozapine; the EMR also lacked evidence of orthostatic blood pressure monitoring. During interview, the clinical manager and RN stated this resident had a fall with major injury and was currently walking only with PT and pivot transferring with staff, and confirmed that neither resident had care planned or ordered interventions to monitor orthostatic blood pressure.
Unattended Care Sheets Violate Resident Privacy
Penalty
Summary
The facility failed to ensure the security and confidentiality of residents' personal health information (PHI) as required by HIPAA standards. During observations, care sheets containing sensitive information about residents, such as their names, room numbers, and specific care needs, were found unattended and exposed in various locations across the facility. On the third floor, a care sheet was left on a covered linen cart in a hallway alcove, accessible to anyone passing by. Similarly, on the fourth floor, a care sheet was left on a medication cart in a common area, and on the second floor, another care sheet was found in an alcove. These sheets contained detailed information about residents' assistance needs, infection control precautions, and other personal details. Interviews with staff members, including nursing assistants and the assistant director of nursing, confirmed the oversight and acknowledged the presence of private information on the unattended care sheets. Staff members admitted that these documents should not have been left unattended and recognized the potential for unauthorized access to sensitive information. The director of nursing also confirmed that care sheets should always be kept out of sight to protect resident privacy, highlighting a systemic issue in maintaining the confidentiality of resident information.
Failure to Conduct Timely Care Conferences
Penalty
Summary
The facility failed to ensure that a resident and/or their representative participated in care conferences for the planning and development of interventions. The resident in question, identified as R36, was noted to have severe cognitive impairment and was dependent on staff for various personal care activities. The resident's medical history included Alzheimer's, dementia, hemiplegia, and malnutrition. Despite the requirement for care conferences to coincide with the Minimum Data Set (MDS) assessments, the facility did not conduct a care conference for R36 after a significant change in status assessment in July 2024. Interviews with facility staff revealed that care conferences were expected to be conducted every three months, aligning with the MDS cycle. However, the director of social services acknowledged that R36's care conference was overdue by one to two months. The family member of R36 confirmed that they had not been invited to a care conference since the summer of 2024. The facility's policy mandates resident and representative involvement in care planning, yet documentation and staff interviews indicated a lapse in adherence to this policy, resulting in the deficiency.
Failure to Update Care Plan for Resident with Foley Catheter and Anxiety Interventions
Penalty
Summary
The facility failed to revise and update a comprehensive care plan for a resident who had a foley catheter, anxiety interventions, and refusals of care not identified in the care plan. The resident, who was admitted to the facility with moderate cognitive impairment and was dependent on staff for toileting and bathing, had a foley catheter placed during a recent hospitalization. However, the care plan was not updated to reflect the current catheter use, and there were no orders related to the catheter in the resident's active orders. Additionally, the care plan did not incorporate interventions from the resident's psychology provider to address anxiety and depression. Observations and interviews revealed that the resident's care plan and care work sheets lacked necessary updates, leading to staff being unaware of the resident's current needs. The nurse practitioner and registered nurse confirmed the absence of catheter-related information in the electronic medical record. The clinical manager and MDS nurse acknowledged the responsibility to update care plans and confirmed that the resident's catheter use should have been care planned. The deficiency was attributed to a lack of real-time updates and communication among the care team, resulting in inadequate care planning for the resident.
Deficiencies in Personal Hygiene and Self-Care for Residents
Penalty
Summary
The facility failed to ensure routine personal hygiene and self-care for residents who were dependent on staff for their care, leading to deficiencies in maintaining a dignified appearance and reducing the risk of complications. Resident R53, who had severe cognitive impairment and was dependent on staff for nearly all self-care, was observed with long fingernails pressing into the palm skin and dark-colored debris under the nails. Despite being identified as needing assistance with personal hygiene, R53's care plan lacked specific nail length preferences, and there was no evidence of nail care being attempted or refused since December 24, 2024. Interviews with staff revealed that nail care was not consistently documented, and R53's family expressed concerns about the lack of basic care. Resident R36, with significant cognitive impairment and dependent on staff for various activities of daily living, was observed with long, jagged toenails and fingernails with dark matter underneath. The care plan indicated that nail care should be done on bath days, but there was a lack of documentation for several weeks, and staff interviews revealed inconsistencies in the approach to nail care. Despite refusals from R36, there was no communication or plan to address these refusals, and the family was not involved in discussions about nail care approaches. Resident R23, with moderate cognitive impairment and dependent on staff for personal hygiene, was observed with disheveled hair and long facial hair, despite expressing a preference to be clean-shaven. The care plan indicated that R23 should be shaved on bath days, but this was not consistently done. Interviews with staff revealed that R23 had been readmitted to the facility with facial hair, and there was uncertainty about why shaving had not been completed. The facility's policy indicated that care and services should be provided for residents unable to carry out activities of daily living independently, but this was not adhered to in the cases of R53, R36, and R23.
Failure to Provide Care-Planned Activities for Non-Verbal Resident
Penalty
Summary
The facility failed to provide or offer care-planned interventions for activities of interest to a resident (R53) who was non-verbal and had severe cognitive impairment. R53's care plan, updated on 11/25/24, indicated preferences for listening to music, watching TV or movies, and social visits. However, observations on 1/14/25 and 1/15/25 revealed that R53 was often left in a silent room with no music or television turned on, despite having a CD player and a television with a list of favorite channels available. Interviews with staff, including a nursing assistant (NA-E) and a registered nurse (RN-D), indicated a lack of communication and coordination between nursing and activities staff. NA-E reported rarely seeing activities personnel engaging with R53 and stated that they were not instructed to play music or turn on the television for him. RN-D also confirmed that they did not turn on the CD player or television, assuming that R53's wife would do so during her visits, which were not consistent. The therapeutic recreation director (TRD) acknowledged that the television should be turned on for R53 as part of his care plan and that all staff should be involved in providing this stimulation. The one-to-one tracking form showed minimal engagement, with only five recorded visits from 12/1/24 to 1/10/25. The facility's policy emphasized involving residents in activities to enhance their psychosocial well-being, but this was not effectively implemented for R53, leading to the deficiency.
Failure to Properly Flush Gastrostomy Tube
Penalty
Summary
The facility failed to ensure that gastrostomy tube water flushes were provided according to physician orders for a resident who was severely cognitively impaired and dependent on staff for all activities of daily living. The resident had multiple diagnoses, including a stroke, diabetes, chronic obstructive pulmonary disease, respiratory failure, convulsions, a gastrostomy, and a tracheostomy. The physician's orders required 150 milliliters of water to be flushed through the feeding tube every four hours. However, during an observation, a registered nurse (RN) administered medications through the gastrostomy tube without measuring the required amount of water to flush the tube, potentially leaving residual medication in the tube. Interviews with the infection control preventionist and the director of nursing revealed that the RN did not follow the expected procedure of flushing the gastrostomy tube with clean water after medication administration. The RN used water from medication cups, which could contain residual thick medications, instead of measuring out the prescribed 150 milliliters of water. This practice was acknowledged by the director of nursing as likely to cause the gastrostomy tube to become plugged. The facility's policy for flushing gastrostomy tubes was requested but not provided.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide comprehensive pain management for two residents, R53 and R70, who were reviewed for pain management. R53, who had severe cognitive impairment and was non-verbal, showed signs of potential pain through facial expressions and physical movements, such as grimacing and raising a clenched fist. Despite these indicators, the facility did not conduct a thorough assessment or implement consistent pain monitoring to ensure R53's comfort. The care plan for R53, which was outdated and lacked revisions, did not adequately address how to monitor or manage his pain, and there was no evidence of ongoing pain assessments or evaluations of the effectiveness of the interventions provided. For R70, who had intact cognition and multiple fractures, the facility also failed to assess and implement non-pharmacological pain interventions. R70's care plan included a list of potential non-pharmacological interventions, but there was no documentation of which interventions had been tried or their effectiveness. The Medication Administration Record (MAR) for R70 showed frequent administration of pain medications without consistent documentation of pain scales or locations of pain, and there was no evidence of non-pharmacological interventions being offered or documented. Interviews with staff revealed inconsistencies in pain assessment and documentation practices. Nursing staff acknowledged the lack of comprehensive pain assessments and monitoring for both residents, and the facility's pain management policy did not provide specific guidance for assessing pain in non-verbal residents. The facility's failure to adequately assess and manage pain for these residents resulted in a deficiency in providing appropriate pain management services.
Failure to Reassess Bed Rail Use for Resident with Impaired Cognition
Penalty
Summary
The facility failed to attempt alternatives and ensure ongoing assessments for safety and appropriate use of side rails for a resident with impaired cognition. The resident, identified as R18, had moderately to severely impaired cognition over time, as indicated by various Minimum Data Set (MDS) assessments. Despite the resident's declining condition and increased need for assistance with bed mobility, the facility did not conduct updated assessments for the safety and appropriate use of side rails since the last assessment in September 2022. The resident's care plan required staff to ensure the side rails were in the upright position and to provide cues for their use, but there was no documentation of attempts to use alternatives or reassessments for the continued need for side rails. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed a lack of awareness and process for ongoing monitoring or reassessment of side rail use. The DON admitted that the facility did not have a process to ensure ongoing bed rail monitoring or reassessment of the resident's risk related to side rail use, especially after significant changes in the resident's condition. The facility's policy on bed safety and bed rails did not specify when or if ongoing resident assessments for safety and appropriate use of side rails were to be completed, contributing to the deficiency.
Failure to Monitor Antipsychotic Medication Efficacy
Penalty
Summary
The facility failed to conduct comprehensive and ongoing behavioral monitoring for a resident, identified as R62, who was administered antipsychotic medication. R62, who had severe cognitive impairment, was observed with facial scrapes due to a fall and was unable to verbally respond to questions. The resident's Medication Administration Record indicated the use of Seroquel for psychosis and major depressive disorder, but there was no evidence of specific target behaviors being tracked to ensure the medication's efficacy. Interviews with staff revealed a lack of clarity regarding the specific symptoms or target behaviors that warranted the use of Seroquel for R62. Nursing staff, including RN-D and NA-D, were unsure of any delusional thinking or hallucinations in R62, and noted that the resident was mostly non-verbal. Despite some observed behaviors such as crying when the significant other left, there was no routine charting of these behaviors, and the medical record lacked documentation of ongoing monitoring of target symptoms or behaviors. The facility's care plan for R62 identified a risk of adverse consequences due to antipsychotic medication use, but it did not specify the symptoms or target behaviors to be monitored. The registered nurse unit manager, RN-E, confirmed the absence of documented target behaviors in the medical record and acknowledged the importance of tracking behaviors to ensure the medication's effectiveness. The facility's policy on psychotropic medication use emphasized the need for identifying target behaviors and monitoring for efficacy, which was not adhered to in this case.
Inadequate Glove Use During Tracheostomy Care
Penalty
Summary
The facility failed to implement appropriate infection control practices during tracheostomy care for a resident on enhanced barrier precautions (EBP). The resident, who was in a persistent vegetative state and had multiple medical conditions including a tracheostomy and gastrostomy, required tracheal suction every shift. During an observation, a registered nurse (RN) administered medications through the resident's gastrostomy tube and then proceeded to perform tracheostomy care without changing gloves in between tasks. This action was contrary to the facility's infection control policy and the CDC guidelines, which require changing gloves when moving from a soiled body site to a clean body site to prevent the spread of infection. Interviews with the RN, another RN, the infection control preventionist, and the director of nursing confirmed that the RN should have changed gloves between the gastrostomy tube medication administration and the tracheostomy care. The facility's hand hygiene policy emphasized the importance of hand hygiene and glove changes to prevent the spread of potentially deadly germs. The failure to change gloves between tasks posed a risk of transferring infection from the gastrointestinal tract to the tracheostomy site, which was acknowledged as a concern by the facility staff.
Delayed Response to Ventilator Alarms for Residents
Penalty
Summary
The facility failed to respond promptly to ventilator alarms for three residents who were dependent on ventilators. Each resident had severe cognitive impairments and required total dependence for all cares and activities of daily living. The ventilator alarms for these residents were not addressed in a timely manner, with delays ranging from several minutes to nearly half an hour. For instance, R2's ventilator alarm sounded repeatedly due to high pressure caused by water condensation in the circuit tubing, which was not immediately addressed by the nursing staff. Similarly, R3's and R4's ventilator alarms were not promptly attended to, with staff acknowledging that alarms should be answered right away but admitting that responses depended on the day's staffing levels. The nursing staff, including RNs and the Director of Nursing, acknowledged the importance of responding to ventilator alarms promptly to assess the type of alarm and address any issues such as obstructions or water in the tubing. However, the facility lacked a clear policy on ventilator alarm response times, and the Director of Nursing could not provide a definitive answer on what constituted a prompt response. The report highlights the facility's failure to ensure timely responses to ventilator alarms, which is critical for the safety and well-being of ventilator-dependent residents.
Deficiencies in Pressure Ulcer Care and Infection Control
Penalty
Summary
The facility failed to adequately monitor and manage pressure ulcers for four residents, leading to deficiencies in care. Resident 1, who had multiple sclerosis, dementia, and functional quadriplegia, developed an unstageable sacral pressure ulcer that was not properly monitored or treated in a timely manner. The wound care nurse documented the ulcer as necrotic with a foul odor and declining healing status, yet there was a delay in obtaining wound care orders, and the resident's family was not notified until the condition worsened, requiring hospitalization and surgery. Resident 2, who was in a persistent vegetative state and dependent on a ventilator, had multiple pressure ulcers, including a Stage 4 ulcer. The facility failed to document nurses' notes for the wound care orders, and there were inconsistencies in the documentation of wound appearance. During an observation, the wound care nurse did not perform hand hygiene between glove changes and used inappropriate materials, such as washcloths, for wound care, which were not in line with infection control practices. Resident 3, who had a Stage 4 pressure ulcer, experienced similar issues with inadequate documentation and improper wound care practices. The wound care nurse used an unlabeled normal saline bottle and did not verify wound care orders before applying dressings. Resident 4, who had dementia, was also affected by the facility's failure to provide proper wound care, as evidenced by the use of tap water instead of normal saline for cleansing wounds. These deficiencies highlight the facility's failure to adhere to proper wound care protocols and infection control practices.
Failure to Notify Provider of Change in Condition Leads to Resident's Death
Penalty
Summary
The facility failed to assess and notify a provider of a change in condition for a resident, resulting in an immediate jeopardy situation. The resident, who had a history of respiratory failure, septicemia, and was ventilator-dependent, was found with a heart rate of 156 bpm, which was outside the acceptable range. Despite this, the registered nurse on duty did not take action or notify a provider. The resident was later found unresponsive with no pulse, and despite CPR being performed, the resident was pronounced dead at the facility. The resident's medical records indicated multiple instances of elevated heart rates that were not addressed or communicated to a provider. The facility's standing orders and hospital discharge summary required notification of a provider for specific changes in condition, such as elevated heart rate and temperature. However, these directives were not followed, and the resident's condition was not adequately monitored or documented, leading to a failure to recognize and respond to the resident's deteriorating condition. Interviews with facility staff revealed a lack of awareness and action regarding the resident's elevated heart rate and other vital signs. Staff members acknowledged that the provider should have been contacted for further direction, and the failure to do so was a deviation from expected nursing standards. The facility's policies required notification of a provider for significant changes in a resident's condition, but these were not adhered to, contributing to the resident's death.
Removal Plan
- All nursing staff on duty including agency/contract nursing staff will be re-educated by DON or designee in relation to: change in condition definitions and what to do when a change in condition occurs, documentation of change in conditions including vital signs, out of range vital signs, what parameters cause alerts in the EHR, and recheck and notify provider if outside of parameters.
- Nursing staff will be educated prior to beginning their next scheduled shift, time clock notifications in place, education emailed out to staff not currently present, and charge of building notified to verify completion of staff during their shift.
- This education will continue until completed with current nursing staff including agency/contract.
- Validation of understanding of education will be verified by random interviews of staff members conducted by DON or designee.
- Further 1:1 education will be provided as needed to reinforce understanding of education provided.
- The policy and procedure for change in condition and documentation of out of range vital signs and follow up with provider all have been reviewed.
Failure to Assess and Treat Pressure Ulcers Leads to Harm
Penalty
Summary
The facility failed to comprehensively assess and provide necessary treatment for pressure ulcers, resulting in harm to a resident who developed a new pressure injury. The resident, who was admitted with a stage 2 pressure ulcer on the right buttock, had multiple medical conditions including quadriplegia, respiratory failure, and dependence on a ventilator. The facility did not have comprehensive wound care orders upon the resident's admission, and there was a lack of documentation and assessment of the existing and new pressure ulcers. The resident's care was further compromised by the lack of management of a cervical collar, which was not removed or assessed for skin integrity due to the absence of orders. Despite the presence of a cervical collar, staff did not receive adequate instructions from the discharging facility or the resident's family, leading to a failure in assessing the skin underneath. This oversight resulted in the development of a pressure ulcer on the back of the resident's head, which was only discovered after the resident was transferred to a hospital. Interviews with facility staff revealed that there was confusion and a lack of communication regarding the management of the cervical collar and the resident's wounds. The facility's assistant director of nursing and director of nursing acknowledged the failure to assess and document the resident's wounds comprehensively. The facility's medical director and nurse practitioner also noted the absence of orders for the cervical collar and the need for specialist evaluation, which contributed to the delay in addressing the resident's skin integrity issues.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency (SA) for a resident who was reviewed for allegations of abuse. The resident, who had diagnoses including aphasia, dementia, and cognitive deficits following a stroke, posted on social media about being physically and emotionally abused by unknown facility staff. The posts included phrases such as 'violence' and 'woman head punch I cry.' Despite these concerning posts, the facility did not report the suspicion of abuse to the SA within the required two-hour timeframe. The administrator and the director of nursing (DON) were aware of the resident's social media posts and discussed the situation in an inter-disciplinary team meeting. However, the administrator did not initially see the posts as a cause for suspicion of abuse, and the DON did not recall how she became aware of the situation. The facility's policy required immediate reporting of suspected abuse, but there was no specific person responsible for filing reports, leading to a failure in reporting the incident to the SA as required.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to conduct and maintain records of a thorough investigation into an allegation of abuse involving a resident with severe cognitive impairments. The resident, who had diagnoses including aphasia and dementia, posted on social media about being physically and emotionally abused by unknown facility staff. Despite the seriousness of the allegations, the facility's investigation was incomplete and lacked proper documentation. The facility's response included a skin assessment by a registered nurse, which found no signs of bruising or redness. An interdisciplinary team meeting was held, and a plan to install a camera in the resident's room was discussed but not implemented due to lack of consent from the resident's family. Interviews with other residents and staff were either not conducted or not documented, and the investigation did not follow the facility's policy for handling such allegations. Interviews with facility staff revealed confusion and lack of clarity about the investigation process. The director of social services and the director of nursing both indicated that the investigation was not thorough, and documentation was incomplete. The facility's policy required a systematic investigation with thorough documentation, which was not adhered to in this case.
Failure to Implement Enhanced Barrier Precautions for Residents
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBPs) for two residents who required them due to their medical conditions. Resident R3, who was in a persistent vegetative state with a history of multidrug-resistant organisms (MDROs), had a tracheostomy, was on a ventilator, and had an indwelling urinary catheter. The care plan for R3 did not address the risk for infection or include interventions for infection prevention, such as the use of personal protective equipment (PPE). During observations, staff members entered R3's room to perform care tasks without using gowns, and there was no signage or PPE cart available to indicate the need for EBPs. Similarly, Resident R4, who had severely impaired cognition and similar medical conditions, also did not have a care plan addressing infection risks or PPE use. Staff performed care tasks for R4 without wearing gowns, and there was a lack of awareness among staff about when EBPs should be implemented. Interviews with staff, including registered nurses and the assistant director of nursing, revealed a lack of knowledge and implementation of EBPs, despite the facility's policy requiring them for residents with indwelling medical devices or chronic wounds.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,049 citations issued within 25 miles in the last 12 months — including the 32 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Minneapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Estates At Chateau Llc | 0.5 mi | ★★★★★ | 14 | 1 |
| Andrew Residence | 0.5 mi | ★★★★★ | 15 | 1 |
| Southside Care Center | 1.3 mi | ★★★★★ | 28 | 1 |
| Fairview University Trans Serv | 1.6 mi | ★★★★★ | 0 | 0 |
| Redeemer Health Care Center | 1.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.