Inspection Reports for Asst Lvg In Heritage Hall
11501 Masonic Home Drive, Bloomington, MN, 55437
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
36% worse than Minnesota average
Minnesota average: 3.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 3
Dec 18, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including fluid balance management, adherence to physician orders, bowel management, and pressure ulcer care.
Findings
The facility failed to consistently implement and accurately track care-planned interventions for fluid balance in a resident on dialysis, failed to follow physician orders and notify providers regarding a resident's refusal to wear a cervical collar, failed to implement and reassess an individualized bowel management protocol for a resident with constipation, and failed to comprehensively assess wounds including weekly measurements for a resident with pressure ulcers.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure care-planned interventions to promote appropriate fluid balance were consistently implemented and accurately tracked for a resident on dialysis with fluid restriction. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow physician orders or notify provider of resident's refusal to wear cervical collar and failed to implement and reassess individualized bowel management protocol for constipation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to comprehensively assess wounds including weekly measurements for a resident with pressure ulcers. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Fluid restriction: 1500
Fluid intake recorded: 820
Fluid intake recorded: 640
Bowel movements: 9
Bowel movements: 11
Bowel movements: 13
Braden scale score: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN-A | Registered Nurse Unit Manager | Reviewed resident R15's medical record and fluid intakes, acknowledged gaps in fluid intake charting |
| LPN-C | Licensed Practical Nurse | Nurse assigned to resident R15's room, verified fluid intake tracking procedures |
| NA-A | Nursing Assistant | Responsible for monitoring and tracking fluid intakes for resident R15 |
| RN-B | Registered Nurse | Observed resident R88 without cervical collar, noted frequent removal |
| NA-E | Nursing Assistant | Assisted resident R88 and noted frequent refusal to wear cervical collar |
| LPN-D | Licensed Practical Nurse and Nurse Manager | Stated cervical collar should be worn at all times and provider should be notified if refused |
| RN-C | Registered Nurse Hospice Nurse | Not aware of resident R88's refusal to wear cervical collar |
| DON | Director of Nursing | Confirmed cervical collar orders and need for notification if refused; confirmed bowel protocol and wound care responsibilities |
| LPN-F | Licensed Practical Nurse | Described bowel management protocol and resident R60's bowel movement status |
| NA-B | Nursing Assistant | Reported resident R60's complaints of abdominal pain and administration of prune juice |
| LPN-G | Licensed Practical Nurse | Confirmed bowel protocol adherence for resident R60 |
| LPN-B | Licensed Practical Nurse | Described bowel protocol and documentation requirements |
| RN-D | Registered Nurse and Wound Care Manager | Responsible for weekly wound assessments and measurements for resident R52 |
| LPN-A | Licensed Practical Nurse and Nurse Manager | Responsible for wound assessments in absence of wound care nurse |
Inspection Report
Annual Inspection
Census: 69
Deficiencies: 9
Oct 19, 2023
Visit Reason
The survey was a recertification annual inspection of Minnesota Masonic Home Care Center to assess compliance with regulatory requirements, including resident rights, abuse reporting, PASARR screening, activities, fall prevention, feeding tube care, respiratory care, and dementia care.
Findings
The facility was found deficient in multiple areas including failure to notify and include transitional care unit residents in resident council meetings, failure to timely report and investigate potential resident-to-resident sexual abuse, failure to complete PASARR screening prior to admission, inadequate provision of meaningful activities for short-term residents, incomplete fall assessments and interventions for a resident with frequent falls, failure to maintain a feeding tube in functioning order, improper cleaning of a CPAP machine, and failure to provide comprehensive dementia care including sexual consent capacity assessments.
Severity Breakdown
Level of Harm - Potential for minimal harm: 1
Level of Harm - Minimal harm or potential for actual harm: 8
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure all residents, including those in the transitional care unit, were notified and afforded opportunity to attend resident council meetings. | Level of Harm - Potential for minimal harm |
| Failed to timely report incidents of potential resident-to-resident sexual abuse to the state agency within two hours for 2 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a potential incidence of sexual abuse was investigated for 2 residents reviewed for potential abuse. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a level I PASARR was completed prior to admission for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a comprehensive agenda and selection of meaningful activities, including group-based activities, was provided or offered for 2 residents on the short-term stay unit. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to comprehensively assess the root cause of falls and incorporate new fall interventions to prevent falls and injury for 1 resident with frequent falls. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a feeding tube was in functioning order to promote comfort, prevent infection, and prevent malnutrition for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure proper cleaning of a CPAP machine to reduce risk of respiratory infection for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure dementia services included initial comprehensive assessment and ongoing assessments regarding sexual consent capacity for 2 residents with cognitive impairment. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 69
Residents affected: 2
Residents affected: 1
Residents affected: 2
Falls: 6
Feeding tube nutrition percentage: 51
BIMS score: 11
BIMS score: 9
BIMS score: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| TRC-B | Therapeutic Recreation Coordinator | Directed activities for the transitional care unit and stated TCU residents were not invited to resident council meetings |
| TRC-A | Therapeutic Recreation Coordinator | Facilitated resident council meetings and managed activities on TCU |
| ACP-A | Associated Clinic of Psychology Staff | Provided psychological assessment and expressed concerns about residents' ability to consent to sexual activity |
| ADON | Assistant Director of Nursing | Aware of sexual relationship between residents, did not report to state agency, and provided sexual health education |
| DON | Director of Nursing | Aware of sexual relationship, deferred assessments to ADON, and confirmed no reporting to state agency |
| NA-D | Nursing Assistant | Witnessed intimate relationship between residents and applied do not disturb sign |
| LPN-D | Licensed Practical Nurse | Observed residents unclothed and intimate, and notified families |
| DOA | Director of Admissions | Responsible for managing PASARRs and unable to locate one for resident R96 |
| NA-B | Nursing Assistant | Reported limited activities on TCU and lack of offering long-term care activities |
| NA-C | Nursing Assistant | Reported limited activities on TCU and lack of offering long-term care activities |
| RN-B | Registered Nurse | Reported limited group activities on TCU and referred activity questions to TRC-A |
| LPN-E | Licensed Practical Nurse and Nurse Manager | Described fall management practices and inability to locate fall report for resident R110 |
| NA-A | Nursing Assistant | Reported resident R110 was high fall risk and should have doorframe indicator |
| LPN-A | Licensed Practical Nurse | Observed and managed feeding tube port taped due to breakage |
| RN-A | Hospice Nurse | Informed of broken feeding tube port but unaware of leakage |
| FM-A | Family Member | Informed of feeding tube issue and stated family would want feedings stopped if tube malfunctioned |
| MD-A | Medical Doctor | Aware of broken feeding tube port but not leakage, concerned about infection risk |
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 12, 2023
Visit Reason
The investigation was conducted due to a complaint regarding a resident (R1) who fell from a full body mechanical lift during transfer, resulting in a head injury and subsequent death.
Findings
The facility failed to ensure adequate support and supervision during the transfer of R1 with a mechanical lift, leading to R1 falling out of the sling and sustaining a fatal head injury. The care plan lacked individualized interventions to manage R1's leaning to the right, and staff re-education was implemented following the incident.
Complaint Details
The complaint investigation found that R1 fell from a mechanical lift due to inadequate support on the right side during transfer. The fall caused a head injury leading to death. The facility's care plan lacked specific interventions for R1's leaning posture. Staff interviews and policy reviews were conducted. The immediate jeopardy was removed after staff re-education and audits.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents, resulting in a resident fall with significant injury and death. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Medication dosage: 5
Time of fall: 11.05
Time of death: 21.43
Number of staff required for transfer: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NA-A | Nursing Assistant | Assisted with transfer and witnessed R1 fall from mechanical lift |
| NA-B | Nursing Assistant | Operated mechanical lift controls during R1's transfer |
| ADON | Assistant Director of Nursing | Led investigation into R1's fall from mechanical lift |
| RN-A | Director of Quality and Reimbursement | Interviewed regarding circumstances of R1's fall |
| DON | Director of Nursing | Responded to incident and oversaw investigation |
| NP-A | Nurse Practitioner | Provided medical information about R1's condition in the emergency department |
| RN-B | Staff Development Nurse | Provided staff re-education on mechanical lift transfers |
Inspection Report
Routine
Deficiencies: 3
Jul 28, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, activities of daily living, accident hazards, and safety measures in the nursing home.
Findings
The facility was found deficient in honoring resident preferences for rising times, providing routine grooming and personal hygiene including facial hair removal, and ensuring safety with the use of bilateral grab bars for a resident with seizures. Deficiencies included failure to adhere to resident rising schedules, lack of routine shaving or documentation of refusal, and inadequate reassessment and monitoring of grab bars after seizure activity.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure identified preferences for rising were honored and implemented for 1 of 2 residents (R39). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure routine grooming and personal hygiene was offered and/or provided for 1 of 7 residents (R65), including lack of facial hair removal. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to comprehensively reassess to ensure appropriateness and safety in bed with use of bilateral attached grab bars for 1 of 1 resident (R195) who developed seizures and continued to use these devices. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Deficiency count: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NA-E | Nursing Assistant | Mentioned in relation to late morning cares for R39 and unawareness of rising preferences |
| RN-E | Registered Nurse Manager | Provided information on resident preferences, care plans, and reassessment of grab bars |
| NA-D | Nursing Assistant | Assisted R65 with morning cares and discussed grooming and shaving practices |
| RN-D | Registered Nurse | Discussed shaving practices and documented seizure event for R195 |
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