MN Veterans Home Silver Bay

In the surveyor’s words

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

• Actual harm, isolatedF760Jan 15, 2025

  Based on interview and document review, the facility failed to ensure medications were administered to the correct resident for 1 of 3 residents (R1) reviewed for medication errors. This failure resulted in actual harm for R1 when she developed bradycardia (abnormally slow heart rate) and became hypotensive (abnormally low blood pressure) which required ongoing monitoring in the emergency department (ED). The facility had implemented appropriate corrective action prior to the onsite investigation, so the deficiency is being cited at past non-compliance. […]

• No harm, potential for more than minimal, widespreadF563Feb 3, 2021

  Based on interview and document review, the facility failed to allow residents to receive visitors. This practice had the potential to affect all 58 residents who resided at the facility, and their families. Findings include: On 2/2/21, at 1:07 p.m. the director of nursing (DON) stated the facility had no residents or staff diagnosed with [REDACTED]. On 2/3/21, at 10:33 a.m. the DON stated the last facility resident tested positive for COVID-19 on 12/18/20, and the last staff-person tested positive on 1/4/21. On 2/3/21, at 10:53 a.m. the DON was interviewed and states she believed the facility was in crisis staffing. The DON stated under guidance, certain exceptions to visitation were allowed which included crisis staffing. […]

• No harm, potential for more than minimal, isolatedF554Apr 16, 2026

  Based on observation, interview, and document review the facility failed to ensure medications weren't left at a resident bedside when the resident was assessed to be unable to self-administer medications. This affected 1 of 1 resident (R41) reviewed for self-administration of medications.Findings include: R41's quarterly Minimum Data Set (MDS) dated [DATE] indicated R41 was cognitively intact. Diagnoses included renal insufficiency, anxiety, and depression R41's Provider Order Summary Report undated, lacked orders to keep medications at bedside. R41's care plan undated, lacked information related to self-administration of medications. R41's Self Administration of Medications &/or Treatments (SAM) dated 3/20/26 indicated R41 did not want to self-administer medications. […]

• No harm, potential for more than minimal, isolatedF609Apr 16, 2026

  Based on interview and document review, the facility failed to report an allegation of staff on resident physical abuse within two hours to the State Agency (SA) for 1 of 4 residents (R54) reviewed for abuse. Findings include:Facility incident report dated 6/7/25, identified on the evening of 6/6/25 at approximately 8:00 p.m., R54 was handled roughly by a staff member, coming in contact with R54's left hand causing injury and pain.R54's progress note dated 6/6/25 at 10:39 p.m., identified staff called to room to assist with resident. […]

• No harm, potential for more than minimal, isolatedF684Apr 16, 2026

  Based on observation, interview, and document review the facility failed to follow provider orders and administer medications as ordered for 1 of 2 residents (R41) reviewed for quality of care.Findings include:R41's quarterly Minimum Data Set (MDS) dated [DATE], identified R41 was cognitively intact. Diagnoses included renal insufficiency, anxiety, and depressionR41's Provider Order Summary Report undated, identified an order for nicotine throat lozenge 4 milligrams (mg), give one lozenge by mouth every hour as needed.During an observation on 4/13/26 at 3:45 p.m., two white pills what R41 stated were nicotine throat lozenges were on the bedside table. During an observation on 4/14/26 at 11:10 a.m., R41 stopped registered nurse (RN)-A and requested two nicotine throat lozenges. […]