Deficiencies (last 3 years)
Deficiencies (over 3 years)
1.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
67% better than Minnesota average
Minnesota average: 3.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Routine
Deficiencies: 2
Date: Sep 12, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations regarding psychotropic medication monitoring, medication administration, and prevention of medication errors in the nursing home.
Findings
The facility failed to ensure orthostatic blood pressure monitoring was consistently performed for residents on psychotropic medications, specifically for 2 of 5 residents reviewed. Additionally, the facility failed to follow physician orders for insulin administration for 1 resident, resulting in medication errors.
Deficiencies (2)
Failure to ensure orthostatic blood pressure monitoring was in place for residents on psychotropic medications (R27, R30).
Failure to follow physician orders for insulin administration for resident R21, resulting in insulin given when blood glucose was below ordered parameters.
Report Facts
Residents affected: 2
Residents affected: 1
Insulin units: 5
Blood glucose levels: 194
Blood glucose levels: 191
Orthostatic blood pressure readings: 137
Orthostatic blood pressure readings: 73
Orthostatic blood pressure readings: 157
Orthostatic blood pressure readings: 68
Orthostatic blood pressure readings: 150
Orthostatic blood pressure readings: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN-A | Registered Nurse | Verified lack of orthostatic blood pressure documentation for R27 and explained monitoring procedures |
| RN-B | Registered Nurse | Reviewed blood glucose levels and insulin administration for R21 and confirmed medication errors |
| LPN-A | Licensed Practical Nurse | Verified insulin administration and blood glucose checks for R21 and acknowledged medication errors |
| DON | Director of Nursing | Stated expectations for orthostatic blood pressure monitoring and insulin administration compliance |
| Consultant Pharmacist | Reviewed R21's medication orders and blood glucose levels, confirmed medication errors and risk | |
| RN-B | Registered Nurse | Reviewed R21's blood glucose levels, insulin administration, and progress notes |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 17, 2023
Visit Reason
Annual survey inspection of The Birches at Trillium Woods nursing home to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 2
Date: Jun 2, 2022
Visit Reason
The inspection was conducted due to allegations of abuse reported by residents and family members, focusing on the facility's failure to timely report suspected abuse to the State Agency as required by regulations.
Complaint Details
The complaint investigation involved allegations of abuse including verbal abuse and physical abuse reported by residents R31, R34, and R35. The facility did not report these allegations to the State Agency within the required two-hour timeframe. The Director of Nursing and Administrator acknowledged the failure to follow reporting timelines and initiated policy revisions and staff education.
Findings
The facility failed to report allegations of abuse within the required two-hour timeframe for 3 of 4 residents reviewed (R31, R34, R35). Additionally, the facility failed to complete annual performance reviews for 3 of 5 nursing assistants, potentially affecting all 32 residents.
Deficiencies (2)
Failure to timely report suspected abuse to the State Agency within two hours for residents R31, R34, and R35.
Failure to complete annual performance reviews for 3 of 5 nursing assistants (NA-A, NA-B, NA-C).
Report Facts
Residents affected by abuse reporting deficiency: 3
Nursing assistants missing annual performance reviews: 3
Total residents at facility: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA-A | Nursing Assistant | Named in deficiency for missing annual performance review. |
| NA-B | Nursing Assistant | Named in deficiency for missing annual performance review. |
| NA-C | Nursing Assistant | Named in deficiency for missing annual performance review. |
| Director of Nursing | Director of Nursing (DON) | Acknowledged failure to complete timely abuse reporting and missing staff performance evaluations. |
| Administrator | Facility Administrator | Acknowledged failure to follow abuse reporting timelines and initiated policy revision and staff education. |
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