Minneapolis Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Minneapolis Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 28, 2024

  The facility identified a census of 44 residents with three residents reviewed for falls and accidents. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1's safety needs were met during transportation from dialysis (a procedure where impurities or wastes were removed from the blood). On 10/21/24, R1 was picked up from dialysis by transportation driver Certified Nurse's Aide (CNA) M, twenty-one miles from the facility. CNA M failed to strap R1's wheelchair into the van with the front safety harnesses. CNA M stopped at the stop light and when he drove away from the stop light, R1's wheelchair fell backwards in the transportation van and R1 hit his head on the wheelchair ramp. […]

• Actual harm, isolatedF689Jan 30, 2023

  The facility identified a census of 41 residents with three reviewed for falls. Based on record review, observation and interview, the facility failed to prevent an avoidable accident when Resident (R) 1 fell out of the transportation van after an appointment due to the brakes to R1's high backed wheelchair were not fully engaged on both sides, resulting in R1's wheelchair rolling and R1 slid out of her wheelchair, falling on the ground, and sustaining a non-displaced humerus (upper arm) fracture. […]

• No harm, potential for more than minimal, widespreadF801May 14, 2025

  The facility had a census of 44 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide the services of a full-time certified dietary manager for the 44 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 05/14/25 at 07:35 AM, observation revealed that dietary staff in the kitchen prepared the breakfast meal. On 05/14/25 at 09:00 AM, Dietary Staff BB verified she was not a certified dietary manager and stated she had completed the course and needed to take the test to become certified. Dietary Staff BB stated the facility had two residents with a pureed diet. […]

• No harm, potential for more than minimal, widespreadF812May 14, 2025

  The facility had a census of 44 residents. Based on observation, interview, and record review, the facility failed to prepare and serve food in a sanitary manner when dietary staff did not complete hair coverage with the hairnet and beard cover. This deficient practice placed the residents of the facility who received meals from the facility at risk for foodborne illness. Findings included: - On 05/12/25 at 07:35 AM, observation revealed dietary staff in the facility kitchen preparing and serving breakfast to the residents. Dietary Staff (DS) CC wore a beard net but did not cover his sideburns or mustache and had a hair net that did not cover the back of his hair. […]

• No harm, potential for more than minimal, isolatedF689Sep 12, 2023

  The facility had a census of 42 residents. The sample included 12 residents, with five reviewed for falls. Based on observation, record review, and interview the facility failed to implement meaningful, resident centered interventions for two sampled residents, Resident (R) 21 and R29, who were at risk and had falls. This placed the residents at increased risk for falls and injury. Findings included: - The Electronic Medical Record (EMR) documented R21 had diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), abnormalities of gait and mobility, unsteadiness on feet, need for assistance with personal care, repeated falls, cognitive communication deficit (an impairment in organization, sequencing, attention, memory,… […]