Allina Health Restorative Suites

In the surveyor’s words

From the most serious findings on record at Allina Health Restorative Suites, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Aug 12, 2025

  Based on interview and document review, the facility failed to ensure the five rights of medication administration were followed for 1 of 3 (R1) residents reviewed for medication error. This resulted in an Immediate Jeopardy (IJ) when registered nurse (RN)-A and licensed practical nurse (LPN)-A administered oxycodone, a narcotic medication, 2-3 times the amount ordered by the provider on five separate administrations. The facility implemented corrective action prior to the investigation so the deficiency was issued at Past Noncompliance.The IJ began on 7/23/25, when R1 was administered the first incorrect amount of 35 milligrams (mg) of Oxycodone HCl (a narcotic pain medication) instead of the provider ordered 15mg. […]

• Immediate jeopardy, isolatedF578Feb 1, 2023

  Based on observation, interview, and document review, the facility failed to ensure resident specific advance directive orders were accurately reflected throughout the medical record for 2 of 2 residents (R232 and R183) reviewed for advanced directives. This resulted in an immediate jeopardy (IJ) for R232 who would have received cardiopulmonary resuscitation (CPR) and R138 who would have been denied CPR, contrary to their wishes, in the absence of a pulse or respirations. The IJ began on [DATE] when R232's Provider Orders for Life-Sustaining Treatment (POLST) identified R232 had an active do-not-resuscitate (DNR) order, however, the physician orders indicated R232 was to be administered CPR. […]

• No harm, potential for more than minimal, widespreadF882Feb 1, 2023

  Based on interview and document review, the facility failed to designate one or more individuals as the infection preventionist who would be responsible for the facility's Infection Prevention and Control Program. This had the potential to affect all 44 residents residing in the facility. Findings include: During the entrance conference on 1/30/23, the director of nursing (DON) stated the facility did not have a designated infection preventionist onsite to facilitate and monitor the infection control program. During interview on 2/1/23, at 7:34 a.m. the DON stated the facility was attempting to hire an infection preventionist but had not done so. […]

• No harm, potential for more than minimal, patternF883Jan 11, 2024

  Based on interview and record review the facility failed to ensure risk and benefits education was provided for 4 of 5 (R22, R15, R25, R86) residents reviewed for influenza and pneumococcal vaccinations. Findings include: R22's admission Minimum Data Set (MDS) dated [DATE], indicated R22 was cognitively intact and had diagnoses of urinary tract infection and sepsis. Furthermore, R22's MDS indicated R22 had declined the influenza and pneumococcal vaccinations. R22's immunization consent assessment dated [DATE], indicated R22 declined the influenza and pneumococcal vaccinations and was not provided an information sheet about the vaccinations. […]

• No harm, potential for more than minimal, isolatedF657Aug 28, 2025

  Based on interview and document review, the facility failed to revise the comprehensive care plan to include individualized person-centered interventions identifying the needed level of supervision to negate the risk of falls for 2 of 3 residents (R2, R3) reviewed for falls.Findings include:R2R2's minimum data set (MDS) assessment dated [DATE], indicated she admitted to the facility on [DATE] with diagnoses including displaced simple supracondylar fracture without intercondylar fracture of the right humerus (broken bone in the lower part of the upper arm), other fracture, history of falling, and other disorder of bone density and structure. R2 had mild cognitive impairment. […]