The Villas at Osseo LLC

In the surveyor’s words

From the most serious findings on record at The Villas at Osseo LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760May 7, 2025

  Based on observation, interview and document review the facility failed to ensure staff followed five rights of medication administration for 1 of 3 residents (R1) reviewed for significant medication errors. R1 received five times the prescribed dose of Methadone for three days (nine shifts) which impaired her speech, ability to verbalize needs and consume nutrition. This resulted in an immediate jeopardy (IJ) for R1. The IJ began on 4/26/25, when the facility staff administrating R1's medication failed to compare the written order on the Medication Administration Record (MAR) with the prescription label on the physical bottle of Methadone before administration which resulted in R1 receiving five times the prescribed dose of Methadone nine times over the course of three days. […]

• Immediate jeopardy, isolatedF600Jan 24, 2025

  Based on observation, interview and document review, the facility failed to protect one of one residents (R4) from abuse and neglect when R4 was deprived of her care planned bed mobility and transfer needs, while she voiced pain and signs of distress, visibly struggled with these movement activities, and was placed in apparent unsafe laying and seated positions. These actions resulted in a fall for R4 where she sustained a distal femur fracture that required hospitalization and surgical intervention. The facility implemented corrective action based on their investigation and so the deficient practice was issued at an immediate jeopardy (IJ) past non-compliance. […]

• Immediate jeopardy, isolatedF689Jan 24, 2025

  Based on observation, interview and document review, the facility failed to ensure adequate supervision to prevent an elopement (leaves premises or a safe area without authorization or necessary supervision) were provided to 1 of 3 residents (R1), who was at risk for elopement, utilized a wanderguard (elopement signaling device), and who had history of independent wanderguard removal. This resulted in immediate jeopardy (IJ) for R1 when she left the facility without staff knowledge and was outside for approximately 30 minutes exposed to lower temperature weather and unsafe conditions. The facility implemented corrective action based on their investigation and so the deficient practice was issued at IJ, past non-compliance. […]

• Immediate jeopardy, isolatedF678Feb 3, 2021

  Based on interview and document review, the facility failed to ensure documentation of a residents code status of do not resuscitate (DNR), do not intubate (DNI) (a tube inserted into an airway to maintain an airway and supplement a resident with oxygen) was documented in the electronic medical record (EMR) when 1 of 1 residents (R1) became unresponsive. This resulted in an immediate jeopardy (IJ) finding for R1 when the resident had a change in condition, stopped breathing and had no pulse, the order for DNR/DNI could not be located and emergency medical services (EMS) initiated cardiopulmonary resuscitation (CPR), including intubation of resident. The immediate jeopardy began on [DATE], after R1's resuscitation preference had changed from DNR-ok with short term intubation, to DNR/DNI. […]

• Actual harm, isolatedF600Jun 10, 2026

  Based on interview, and record review the facility failed to ensure residents were free from resident to resident abuse for 5 of 5 residents (R3, R5, R6, R7, & R8) reviewed when R1 had physically assaulted R3 and R5 and verbally assaulted all five residents resulting mental anguish and multiple police visits.Findings include: R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMS) score of 14 indicating R1 was cognitively intact. R1 did not exhibit any behaviors and did not refuse cares. R1 used a walker and/or a cane for ambulation. He was independent with eating, putting on and taking off footwear, personal hygiene, rolling in bed, sitting to lying and lying to sitting. […]