Solaris Healthcare Forest Lake

In the surveyor’s words

From the most serious findings on record at Solaris Healthcare Forest Lake, in the surveyor’s own words.

• Immediate jeopardy, isolatedF578Jul 19, 2023

  Based on interview and record review, the facility failed to implement procedures to ensure a resident's wishes related to health care treatments and procedures at the end of life were followed and failed to honor an advance directive that reflected the decision to withhold cardiopulmonary resuscitation (CPR) for 1 of 8 (#1) sampled residents reviewed for resident rights and CPR. These failures contributed to resident #1 receiving CPR in violation of an explicit wish for a natural and dignified death. There was likelihood resident #1 experienced severe pain, and could have suffered broken bones, organ damage and a prolonged dying process. On [DATE] at approximately 4:47 AM, resident #1 was found unresponsive with no heart rate and no respirations. […]

• Immediate jeopardy, isolatedF678Jul 19, 2023

  Based on record review and interview, licensed nurses and respiratory therapists failed to follow the facility's policy and procedure for Cardiopulmonary Resuscitation (CPR) related to verification of physician orders for resuscitation or code status in an emergency and process for following the Do Not Resuscitate Order (DNRO) for 1 of 8 residents reviewed for advance directives (#1). On [DATE] at approximately 4:47 AM, resident #1 was found unresponsive with no heart rate and no respirations. A Respiratory Therapist (RT) initiated CPR without first verifying the resident's physician orders and advance directives (code status) in the medical record. Emergency Medical Services (EMS) arrived at the facility and spoke to the resident's spouse who confirmed the resident had a DNRO. […]

• No harm, potential for more than minimal, patternF644Mar 27, 2025

  Based on interview, and record review, the facility failed to ensure completion and accuracy of Level I Preadmission Screening and Resident Reviews (PASARRs) on admission, and/or failed to make referrals for newly evident or possible mental disorders to evaluate the need for specialized mental health services or alternate placement for 7 of 7 residents reviewed for PASARR, of a total sample of 53 residents, (#17, #199, #136, #19, #185, #9 and #72). Findings: 1. Resident #17's medical record revealed she was admitted to the facility on [DATE] from an acute care hospital with a diagnoses including diverticulitis, fibromyalgia, generalized anxiety disorder, and major depressive disorder. […]

• No harm, potential for more than minimal, isolatedF755Jul 11, 2025

  Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure medications were administered according to acceptable standards of practice for 1 of 2 residents observed during a medication administration pass, of a total sample of 9 residents, (#3).Findings:Resident #3 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, personality disorder, depressive disorder, persistent mood disorder, and hyperlipidemia. Review of the Minimum Data Set admission Assessment with an Assessment Reference date of 6/25/25 revealed resident #3 had a Brief Interview for Mental Status score of 15/15, which indicated the resident was cognitively intact. […]

• No harm, potential for more than minimal, isolatedF759Jul 11, 2025

  Based on observation, interview, and record review, the facility failed to prevent medication errors related to not following physicians' orders for 1 of 2 residents sampled for medication administration, of a total sample of 9 residents, (#6). There were 2 medication errors in 11 opportunities, for a medication error rate of 18.18%.Findings:Resident #6 was admitted to the facility on [DATE] with diagnoses including asthma, hyponatremia (low sodium), hypertension, gastro-esophageal reflux, osteoarthritis, and chronic kidney disease. On 7/10/25 at 9:15 AM, Licensed Practical Nurse (LPN) A prepared resident #6's scheduled morning medications. […]