MN Veterans Home Minneapolis: CPR Given to DNR Resident - MN
The Minnesota Veterans Home in Minneapolis is a state-run facility serving veterans who fought in wars from World War II through more recent conflicts. The inspection, triggered by a complaint, was completed in September 2025 and found that a nurse had performed cardiopulmonary resuscitation on a resident whose POLST form, a Physician Orders for Life-Sustaining Treatment, clearly designated him as do-not-resuscitate.
The nurse found the resident unresponsive. She left the room to call the on-duty supervisor and to look up his code status. She still had her gloves on when she left. When she returned, she started CPR.
She had, she later said, checked the POLST. She saw a check mark. She read it as "attempt resuscitation."
It said do not resuscitate.
The next day, a staff member told her she had read the form wrong. She looked again. The check mark she had seen was next to "Do not resuscitate." She had misidentified which box had been marked.
The POLST system used at the facility included a color-coded indicator on the chart spine: white for a full code, blue for a DNR. The resident's chart spine was blue. The nurse, who had received training on reading POLST forms, told inspectors she now understood how the color system worked. She had not applied that knowledge in the moment she needed it most.
The facility's own emergency protocol, in place before the incident occurred, required nurses to review a resident's code status before beginning CPR, either through the electronic medical record or through the POLST located in the resident's chart. The protocol existed precisely to prevent what happened. It did not prevent it.
What the inspection report does not say is also worth noting. It does not say the resident survived. It does not say he died. It records only that CPR was performed on a man who had made a documented, legally recognized decision that he did not want CPR performed on him, and that a nurse did not correctly read the document recording that decision.
The POLST form is one of the most consequential documents in a nursing home. It translates a resident's wishes about end-of-life care into medical orders that are supposed to govern what staff do in an emergency. Residents and families spend significant time working with physicians and social workers to complete these forms. The entire system depends on staff being able to read them accurately under pressure, in the seconds before they decide whether to begin chest compressions on an unresponsive person.
At the Minnesota Veterans Home in Minneapolis, that system failed.
Immediate jeopardy is the most serious citation level available to federal inspectors. CMS defines it as a situation in which a facility's failure to meet a requirement has caused, or is likely to cause, serious injury, harm, impairment, or death. It is not issued for paperwork problems or procedural lapses in the abstract. It is issued when inspectors determine that residents faced, or are facing, a threat to their lives or physical safety.
The facility did not dispute the finding. After inspectors identified the deficiency, the home moved quickly to address it. Health unit coordinators, nurse managers, and registered nurses went through all resident charts to verify that each POLST matched both the electronic medical record and the color-coded spine label on the chart. Staff were educated on emergency protocols, specifically where to find code status and how to read it. The facility required that two people verify a POLST before any code response, a change from the single-nurse review that had been in place. Monthly code drills were implemented, during which staff practice reading POLST forms and correctly identifying whether a resident is a full code or DNR. An ongoing audit schedule was put in place to evaluate whether staff retained that knowledge over time.
Inspectors determined that the immediate jeopardy was removed after the facility completed those corrective steps.
The deficiency is listed under F0578, which covers a resident's right to formulate advance directives and to have those directives honored. It is not a clinical care deficiency in the traditional sense. It is a rights violation. The veteran in this case had exercised one of the most fundamental rights available to him as a patient: the right to say, in advance and in writing, what he wanted done to his body at the end of his life. That right was not honored.
The inspection report describes the incident as "past noncompliance," meaning the immediate jeopardy had already been identified and corrected before the report was finalized. The facility's corrective plan was accepted. The citation stands.
What does not appear in the report is any account of what was said to the resident's family, if he had family, or whether anyone sat with them to explain that the wishes he had documented were not followed in his final moments. The report does not say whether the resident was conscious at any point after the CPR began, or what his condition was when emergency responders arrived, or what happened to him after that night.
The nurse who performed the compressions told inspectors she had training on POLST forms. She knew, in the abstract, how to read them. She left the room to check the code status, which was the right instinct. She returned and started CPR, which was the wrong outcome. She found out the next morning, when a colleague told her she had read the form incorrectly, that the man she had tried to save had not wanted to be saved that way.
The color-coded spine label was blue.
She had been trained on what blue meant.
The gap between knowing something in a training session and applying it correctly in the dark of an emergency, with gloves still on from whatever she had been doing before she found him, is the gap this inspection report lives in. It is also the gap that the facility's corrective plan is now designed to close, through drills and audits and dual verification and monthly practice reading the same forms under conditions that approximate, as closely as a drill can, the conditions of a real emergency.
Whether those measures hold, and whether the next nurse who finds a veteran unresponsive in the middle of the night reads the blue spine label correctly and puts her hands back at her sides, is not something an inspection report can answer.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mn Veterans Home-mpls from 2025-09-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 14, 2026 · Our methodology
MN VETERANS HOME-MPLS in MINNEAPOLIS, MN was cited for violations during a health inspection on September 22, 2025.
The Minnesota Veterans Home in Minneapolis is a state-run facility serving veterans who fought in wars from World War II through more recent conflicts.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.