Citations in Minnesota
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Minnesota.
Statistics for Minnesota (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Minnesota
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A resident with intact cognition who wished to move closer to family did not receive adequate discharge planning, as the facility failed to document or follow up on referrals and updates related to the discharge process. Staff interviews confirmed a lack of ongoing communication and follow-up, despite the facility's policy requiring continuous evaluation of discharge goals.
A resident with central spinal cord syndrome did not receive a physical therapy evaluation as ordered after a care conference where the need for additional PT was discussed. Although a provider order for PT was entered, staff interviews confirmed that the evaluation was not completed due to a lapse in follow-through, and the facility could not provide a relevant therapy policy when requested.
A resident with a history of urethral stricture and obstructive uropathy had an indwelling urinary catheter in place for an extended period without documented clinical justification, periodic reassessment, or attempts at removal, despite experiencing multiple catheter-associated UTIs, including one resulting in hospitalization. Staff confirmed the absence of trial removal or timely urology referral, and the care plan lacked detail regarding catheter management.
Two residents who were dependent on staff for ADLs did not receive routine personal hygiene, including showers, hair care, and shaving. One resident was left with a long beard despite requesting to be shaved, and another was observed with matted hair and lacked documentation of recent bathing or grooming. Staff interviews and records confirmed that personal hygiene care was not consistently provided or documented according to facility policy.
Several residents with specific dietary needs, including those requiring large portions for malnutrition and wound healing, and one requiring yogurt or cottage cheese for weight gain, did not consistently receive the prescribed food portions or supplements. Additionally, a resident with a fluid restriction order was able to access fluids freely without monitoring or education from staff. Staff interviews and observations confirmed that dietary and fluid orders were not consistently followed.
The facility did not provide care and treatment in accordance with physician orders and the resident’s stated preferences and goals, as identified through surveyor observation and record review.
A resident who required dialysis did not receive safe and appropriate dialysis care and services as needed. The facility did not ensure that dialysis care was provided according to the resident's requirements.
A resident with a history of smoking violations was allowed to keep smoking materials in her room and continued to smoke there despite facility policy requiring smoking only in designated areas. Staff observed evidence of smoking in the resident's bathroom, and interviews confirmed ongoing non-compliance. The resident refused to have smoking materials stored at the nursing station, and staff found it difficult to supervise her due to her insistence on privacy.
Staff did not deliver care or services in a manner that was trauma informed or culturally competent, failing to meet required standards for addressing residents' trauma histories or cultural needs.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Ensure Adequate Discharge Planning and Follow-Up
Penalty
Summary
The facility failed to maintain an adequate discharge planning process to ensure a resident's preference for discharge was met. The resident, who had intact cognition and no behavioral or psychiatric issues, expressed a desire to move closer to family in a neighboring state. Although the care plan indicated that the resident and family were seeking a skilled nursing facility (SNF) in the desired area and that referrals had been initiated, there was a lack of documentation regarding where referrals were sent, updates on the status of those referrals, or outcomes from the MNchoice assessment. Progress notes showed some referrals and assessments were made, but did not include follow-up information or communication with the resident or family about the discharge process after certain dates. Interviews with staff revealed that there was no evidence of follow-up on discharge plans or referrals in the electronic medical record since the last care conference, despite the resident's ongoing wish to discharge. The social services director acknowledged the absence of follow-up, and the director of nursing stated that the expectation was for social services to remain involved and for resources to be set up for a safe discharge in a timely manner. The facility's own discharge planning policy required continuous evaluation and implementation of interventions to address discharge goals, which was not reflected in the documentation or actions taken for this resident.
Failure to Provide Ordered Rehabilitative Services
Penalty
Summary
A resident with central spinal cord syndrome and a history of receiving physical, occupational, and speech therapy did not receive specialized rehabilitative services as ordered. The resident's care plan was updated to include passive range of motion (PROM) and instructions to follow physical therapy (PT) orders. During a care conference, the resident and family requested additional PT due to observed movement in the resident's lower extremities. A provider subsequently ordered a PT evaluation, but the evaluation was not completed after the order was written. Interviews with staff revealed that the PT order was not acted upon, with the LPN confirming that the order "fell through the cracks." The director of nursing stated that the expectation was for therapy to evaluate residents within 72 hours of a new order and to communicate the therapy plan to nursing staff within one week. Despite these expectations, the resident was not evaluated by PT after the new order, and the facility was unable to provide a policy for therapy services when requested.
Failure to Document and Reassess Indwelling Catheter Use
Penalty
Summary
The facility failed to ensure appropriate clinical decision-making and documentation regarding the use of an indwelling urinary catheter for one resident. The resident, who was cognitively intact and independent with activities of daily living, had a history of urethral stricture and obstructive and reflux uropathy. Despite these diagnoses, the medical record did not contain documentation of the reason for the catheter's insertion, justification for its continued use, or evidence of periodic reassessment. There was also no documentation of any attempt to remove the catheter or a referral to urology for further management until recently, even though the resident had experienced multiple urinary tract infections (UTIs) associated with the catheter, including one that resulted in hospitalization for sepsis. Interviews with staff confirmed that no trial removal of the catheter had been attempted since the resident's admission, and the care plan only referenced long-term catheter use without further detail. The resident reported a history of frequent UTIs and expressed that the catheter was intended to remain until he could stand and care for himself, based on previous medical advice. The facility's electronic medical record lacked evidence of ongoing assessment or a clear plan for catheter management, and no relevant policy was provided upon request.
Failure to Provide Routine Personal Hygiene for Dependent Residents
Penalty
Summary
The facility failed to ensure that routine personal hygiene, including showers, hair care, and shaving, was completed for two residents who were dependent on staff for activities of daily living (ADLs). One resident, who was cognitively intact but had significant physical impairments and was dependent on staff for all personal hygiene, was observed with a two-inch long beard despite expressing a preference to be clean-shaven. Documentation and care plans lacked specific instructions or preferences regarding shaving, and staff interviews confirmed that the resident had been requesting to be shaved for several weeks without the request being fulfilled due to staff being too busy. Another resident, also cognitively intact but with multiple medical diagnoses and a self-care deficit, required staff assistance for bathing, dressing, grooming, and oral hygiene. The care plan did not include the resident's preferences or evidence of refusals for bathing or assistance. Weekly skin assessments and progress notes showed repeated refusals of baths, but there was no documentation of staff offering additional opportunities for bathing or partial baths, nor was there evidence of staff reapproaching the resident or documenting interventions. Observations revealed the resident appeared disheveled with a large, matted clump of hair, and staff interviews confirmed the lack of recent bathing and grooming. The facility's policy required that care and services be provided based on comprehensive assessment and resident needs and choices, to ensure that abilities in ADLs do not diminish unless unavoidable. However, the lack of documentation, failure to follow up on resident requests and preferences, and insufficient attempts to provide or document personal hygiene care led to the deficiency identified during the survey.
Failure to Follow Dietary and Fluid Restriction Orders
Penalty
Summary
The facility failed to follow established nutritional interventions and dietary orders for several residents, resulting in deficiencies in the provision of adequate food and fluids. Three residents with specific dietary needs, including large portions for wound healing and malnutrition, and the addition of yogurt or cottage cheese for weight gain, did not consistently receive the prescribed food portions or supplements. Observations and interviews revealed that residents who were supposed to receive double or large portions were served meals of the same size as other residents, and one resident did not receive the ordered yogurt or cottage cheese with meals. Staff interviews confirmed that the intended larger portions were not being provided, and the dietary staff did not consistently follow meal tickets or care plans specifying these interventions. Additionally, the facility failed to ensure that a fluid restriction order was followed for a resident with hyponatremia. The resident was observed drinking fluids freely from large containers, and staff reported that they were unable to monitor her intake because she was independent in obtaining fluids. There was no documentation of education or risk versus benefit discussions with the resident regarding the importance of adhering to the fluid restriction. The resident herself stated that she had not received any education from facility staff about her fluid restriction or its significance. Facility policies were reviewed and indicated that food and nutritional needs should be met according to physician orders, and that therapeutic diets should be prepared and served as prescribed. However, the observed practices did not align with these policies, as residents did not receive the prescribed diets or fluid restrictions. The lack of adherence to dietary and fluid orders was confirmed through staff interviews, resident statements, and direct observation of meal service and resident behavior.
Failure to Follow Physician Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and record review, which indicated that care provided did not align with the documented orders or the expressed wishes and objectives of the resident. Specific details regarding the resident’s medical history or condition at the time of the deficiency were not provided in the report.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such treatment. The report notes that the facility failed to ensure that the necessary dialysis care was provided in accordance with the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as the resident's medical history or condition at the time, are not provided in the report.
Failure to Prevent Smoking Hazards for Resident with Repeated Violations
Penalty
Summary
A resident with a history of smoking violations was not adequately protected from potential smoking-related accidents. The resident was assessed as having adequate memory and cognitive function and was care planned to smoke independently, with interventions including smoking in her room, no smoking signs, and not allowing removal of cigarettes. Despite these interventions, documentation and staff interviews confirmed that the resident repeatedly smoked in her room, in violation of facility policy, and kept all smoking materials in her possession. Observations revealed evidence of smoking in the resident's bathroom, including a plastic cup with tar-colored liquid, coffee grounds, a strong odor of smoke, loose tobacco on the floor, and a bag of loose tobacco on the resident's wheelchair. Staff interviews indicated that the resident would not allow staff into her room without knocking and waiting for a response, making supervision difficult. The resident refused to have her smoking materials stored at the nursing station, despite being assessed as unsafe with her own smoking materials. The facility's policy required residents to smoke only in designated areas and allowed for revocation of smoking privileges for non-compliance, but the resident continued to smoke in her room. The administrator and DON confirmed the facility's policy and the ongoing non-compliance.
Failure to Provide Trauma-Informed and Culturally Competent Care
Penalty
Summary
The facility failed to provide care or services that were trauma informed and/or culturally competent. This deficiency indicates that staff did not consider or incorporate trauma-informed approaches or cultural competence in the delivery of care or services to residents, as required. The report does not specify the number of residents affected or provide details about their medical history or condition at the time of the deficiency.
Some of the Latest Corrective Actions taken by Facilities in Minnesota
- Provided comprehensive nurse education on medication administration and transcription, the five rights, label–order matching, and protocols for pharmacy/physician clarification (J - F0760 - MN)
- Delivered training on medication types, high-risk drugs, error prevention, and national safety standards (J - F0760 - MN)
- Initiated ongoing compliance audits of medication practices (J - F0760 - MN)
Failure to Follow Five Rights of Medication Administration Leads to Significant Methadone Overdose
Penalty
Summary
Facility staff failed to follow the five rights of medication administration for a resident with multiple complex medical conditions, including Multiple Sclerosis, paraplegia, and chronic pain. The staff did not compare the written order on the Medication Administration Record (MAR) with the prescription label on the Methadone bottle before administration. As a result, the resident received five times the prescribed dose of Methadone over the course of three days, totaling nine incorrect administrations. The error occurred because staff administered Methadone based on outdated or incorrect information, specifically using the concentration and dosing instructions from a discontinued medication bottle rather than the current prescription. Multiple nurses, including agency staff, RNs, and LPNs, administered the incorrect dose, each failing to verify the medication concentration and dosage as indicated on the new prescription bottle. The MAR and narcotic record contained conflicting information, and staff relied on these records without cross-checking the actual medication label, leading to repeated overdoses. The resident experienced a significant decline following the medication errors, including impaired speech, inability to verbalize needs, decreased oral intake, lethargy, and increased weakness. Observations and interviews with staff and the resident's significant other confirmed these changes, noting that the resident was previously able to speak and eat but became largely nonverbal and unable to tolerate food or oral medications after the errors. The medication error was discovered during a medication count, and subsequent interviews revealed that staff had not recognized the change in medication concentration or the impact of the error until the resident's condition had significantly deteriorated.
Removal Plan
- Provide education to nurses on medication administration and transcription, the five rights of medication administration, ensuring medication labels match physician orders, and contacting pharmacy or physician for clarification.
- Educate all nurses on medication types, prevention of errors, high risk medications, and compliance with national safety standards.
- Review pain medication management for accuracy and ensure the label on the bottle matches the physician order in the medical record.
- Review orders and liquid medication labels for all like residents to ensure labels on bottles match the orders in the medical record.
- Initiate compliance audits.
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