MN Veterans Home-Luverne

In the surveyor’s words

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

• Actual harm, isolatedF689Jan 14, 2026

  Based on interview and document review, the facility failed to provide safe transfer for 1 of 1 resident (R1) who required the use of a mobility van mechanical lift. This resulted in actual harm when R1 fell from the mobility van to the ground which resulted in significant ongoing pain, administration of pain narcotics and a decrease in activities of daily living (ADL)s. The facility implemented corrective action prior to the investigation, so the deficiency was issued at Past Noncompliance. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 had moderately impaired cognition, no behaviors, and no rejection of cares. R1 required staff assist with dressing, personal hygiene, and transferring. R1 required a manual wheelchair but was independent with mobility. […]

• No harm, potential for more than minimal, widespreadF755Dec 4, 2024

  Based on observation, interview and document review the facility failed to ensure 1 of 1 narcotic emergency kit (E-Kit) was replaced prior to the pharmacy date of expiration documented on top of kit. This had the potential to affect all residents. Findings include: Observation on [DATE] at 4:40 p.m. with registered nurse (RN)-A of the [NAME] Wing medication room, identified the narcotic E-Kit, with a red numbered tag lock, and a bright green pharmacy sticker which listed the expiration date of [DATE]. The label directed to notify pharmacy 7 days prior to this date for replacement. Interview on [DATE] at 4:42 p.m. […]

• No harm, potential for more than minimal, patternF700Oct 4, 2023

  Based on observation, interview, and document review, the facility failed to ensure side rails were assessed to determine appropriateness and safety of use for 4 of 4 residents (R9, R16, R30 and R31) who was observed to have a side rails affixed to their beds. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], identified R9 was cognitively intact and required extensive assistance with bed mobility and transfers. R9's diagnoses included traumatic brain dysfunction (head injury causing damage to the brain by external force or mechanism), hemiplegia (condition that causes paralysis or weakness on one side of the body) and contracture of muscle, multiple sites. […]

• No harm, potential for more than minimal, patternF880Dec 14, 2022

  Based on interview and document review the facility failed to conduct infection control surveillance immediately upon discovering 2 staff members developed COVID-19-like symptoms, to prevent the spread of COVID-19 according to Centers for Disease Control and Prevention (CDC) guidelines. This deficient practice had the potential to effect 39 out of 62 residents at the facility. The facility also failed to ensure all staff COVID-19 rapid self-test results were documented according to CDC guidelines and failed to appropriately disinfect 1 of 1 glucometer in between resident use. Finding include: SURVEILLANCE Review of the Employee Illness Tracking Form dated 12/11/22, indicated RN-M called in sick for her shift from 3:00 p.m. to 11:00 p.m. […]

• No harm, potential for more than minimal, isolatedF684Jul 1, 2026

  Based on interview and document review, the facility failed to ensure a change of condition was identified and assessed by a nurse to determine what, if any, additional intervention maybe needed for 1 of 2 residents (R1) reviewed. R1 developed audible gurgling and potential respiratory impairment on [DATE] in the mid-afternoon which was not comprehensively assessed by a nurse until several hours later. Findings include: On [DATE] at 11:46 a.m., an interview was held with emergency medical technician (EMT)-E who stated they were on a crew that responded to the care center for R1 on [DATE], with reported respiratory distress. They arrived and found R1 lying in bed and very clearly in respiratory distress. […]