MN Veterans Home-Fergus Falls

In the surveyor’s words

From the most serious findings on record at MN Veterans Home-Fergus Falls, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Apr 27, 2026

  Based on interview, observation and document review the facility failed to provide adequate supervision and monitoring to prevent resident to resident physical abuse for 1 of 1 resident (R1) reviewed for abuse when R2, who had a history of verbal and physical aggression towards staff and residents went into R1's room, allegedly grabbed him by the neck and threw him to the floor before leaving the room with R1's cane. Following the incident, the facility failed to provide adequate supervision and monitoring to ensure residents were protected from physical abuse putting them at the likelihood for serious harm, impairment or death when R2 continued to exhibit behaviors such as wandering into other resident rooms unsupervised. […]

• Actual harm, isolatedF689Dec 4, 2025

  Based on observation, interview and document review, the facility failed to implement standards of practice to ensure a safe transfer for 1 of 3 residents (R1) reviewed for accidents when staff failed to properly attach the lift sling to the ceiling lift bar. This resulted in actual harm when R1 fell from the lift during a staff assisted transfer, sustained a large 5 centimeter (cm) contusion (a severe injury caused by a direct blow to the head leading to bruising/swelling of the brain tissue)/hematoma (blood leaks from tiny brain vessels causing swelling) to the occipital scalp (rearmost portion of the head constitutes the posterior section of the brain and skull) and was sent to the emergency department (ED) requiring medical evaluation and pain that persisted requiring medication for… […]

• No harm, potential for more than minimal, widespreadF563Jul 7, 2021

  Based on interview and document review, the facility failed to provide routine indoor visitation according to the Centers for Disease Control (CDC) guidance when a facility was not in COVID-19 outbreak status for 2 of 3 residents (R1, R3) who were able to voice concerns about indoor visitation. This practice had the potential to affect all 96 residents residing in the facility. Findings include: The CDC guidance Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination dated 4/27/21, identified indoor visitation could be permitted for all residents when the county positivity rate was less than 10%, more than 70% of residents in the facility are fully vaccinated, and the facility was not in outbreak status. […]

• No harm, potential for more than minimal, patternF610Dec 4, 2025

  Based on interview and document review, the facility failed to provide sufficient protection to other residents while the investigation was completed for 1 of 3 residents (R1) who was reviewed for accidents. This had the potential to affect all 9 residents who required staff assistance with total body lift transfers.Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified he was admitted to the facility on [DATE], from a skilled nursing facility. He had severely impaired cognition, disorganized thinking, and physical behavioral symptoms directed toward others (hitting, kicking, pushing, scratching, grabbing). He was dependent upon staff for all transfers. […]

• No harm, potential for more than minimal, isolatedF689Feb 5, 2025

  Based on observation, interview and document review, the facility failed to accurately assess and implement safe smoking interventions for 1 of 1 resident (R17) reviewed for smoking. Findings include: R17's quarterly Minimum Data Set (MDS) dated [DATE], indicated R17 had diagnoses which included chronic obstructive pulmonary disease (COPD) hypertension (elevated blood pressure), and stroke. Identified R17 had severe cognitive impairment and was independent with activities of daily living (ADL's) which included transfers and toileting. Identified R17 used tobacco. R17's annual Care Area Assessment (CAA) dated 5/1//24, identified interventions were in place to address safety needs. […]