Minnesota Masonic Home Care Center

In the surveyor’s words

From the most serious findings on record at Minnesota Masonic Home Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 12, 2023

  Based on interview and document review, the facility failed to ensure one of three residents (R1) remained free of an avoidable accident with significant injury when R1 was transferred using a full body mechanical lift, and fell to the ground. R1 sustained a head injury that required treatment in the emergency department (ED). R1 died that same day from the head injury sustained during the fall from the lift. The deficient practice was identified as an immediate jeopardy (IJ) situation; however, the provider had implemented corrective action prior to the investigation, so the deficiency remained as past non-compliance. […]

• No harm, potential for more than minimal, patternF921Feb 12, 2026

  Based on observation, interview and document review, the facility failed to ensure the D1 unit shower room was maintained in a clean, sanitary manner when 25% of the shower walls were observed to be covered with unidentified pink matter. This had the potential to affect 27 of the 29 residents who resided on D1 and utilized the shower room on a routine basis.Findings include:During observation on 2/11/26 at 9 a.m., pink matter deposits were observed on the shower walls. The shower walls were covered with white tiles, and the pink matter was observed over the caulking lines and the baseboard tiles. […]

• No harm, potential for more than minimal, isolatedF558Feb 12, 2026

  Based on observation, interview, and document review, the facility failed to accommodate resident needs by ensuring the call light was accessible for 2 of 2 residents (R144, and R45) reviewed for call lights. Findings include: R144 R144's annual comprehensive Minimum Data Set (MDS) dated [DATE], indicated R144 had severe cognitive impairment, had no behaviors and didn't refuse cares. MDS indicated she had bilaterally impaired range of motion, needed substantial assistance with showers, upper body dressing, transfers and bed mobility. MDS also indicated R144 was dependent on toileting hygiene, bathing, lower body dressing and oral hygiene. […]

• No harm, potential for more than minimal, isolatedF657Feb 12, 2026

  Based on observation, interview, and document review, the facility failed to revise the care plan to include the methods staff utilized and found effective for behavioral de-escalation for 1 of 1 residents (R101) reviewed for behavioral symptoms of dementia. Findings include:R101's quarterly Minimum Data Set (MDS) dated [DATE], indicated R101 had severely impaired cognition and a diagnosis of dementia. The MDS indicated R101 was dependent on staff for most activities of daily living. R101's care plan dated 3/27/25, indicated that R101 was resistant to care and taking medications, as well as having delusional thoughts at times. […]

• No harm, potential for more than minimal, isolatedF695Feb 12, 2026

  Based on observation, interview and document review the facility failed to ensure residents using a continuous positive airway pressure (CPAP) machine had appropriate orders for use to include equipment setting and humidification as appropriate for 3 of 3 residents (R1, R91, and R150) reviewed for respiratory equipment. Findings include: R1 R1's significant change in status (SCSA) Minimum Data Set (MDS) dated [DATE] identified R1 with intact cognition, required substantial assistance for toileting, dressing, and hygiene. In addition, diagnoses include heart failure, kidney disease, obstructive sleep apnea (OSA) and dependence on oxygen. […]