Mn Veterans Home-fergus Falls
MN VETERANS HOME-FERGUS FALLS in FERGUS FALLS, MN — inspection on April 27, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
whereabouts on the unit more closely. On 4/10/26 at 6:28 p.m., provided [R2] with 1:1 supervision by
jeopardy to resident health or cooperative, and did not recall an incident occurring. On 4/10/26 at 8:55 p.m., ED provider had talked safety to psych medical doctor (MD), administered 50 mg of Seroquel (Quetiapine Fumarate).
Will be sending [R2] back to facility with written orders: Seroquel scheduled twice a day (b.i.d.) and PRN. On
next week. If conditions worsen return to ED.
Discussed with wife if family would be available during specific times on Saturday and Sunday.
Maybe difficult due to grandchild sporting event. On 4/11/26 at 5:45 a.m., [R2] slept all shift after he arrived back to facility at 10:22 p.m.
Every 15-minute checks completed for his shift. On 4/11/26 at10:51 a.m., Woke up at 9:00 a.m., ate breakfast and was calm.
Staff continued every 15-minute checks.
Spoke with wife, she will be coming in at 2:00 p.m. to sit with resident as he becomes more agitated and busier in the afternoons. On 4/11/26 at 1:35 p.m., Staff provided very 15-minute checks, gets busy, wandering, busy easily redirected. On 4/11/26 at 2:21 p.m., Wife here sitting in [R2's] room with him.
Continuing to monitor. On 4/11/26 at 10:27 p.m., Wife here from 2:00 p.m. to 4:00 p.m. [R2] has been pleasant currently sitting with staff. On 4/13/26 at 12:06 p.m., scheduled an appointment for 4/16/26 with psych. On 4/13/26 at 10:03 p.m., [R2's] Behaviors heightened before supper time. He was hard to redirect and refused cares multiple encouragements.
When given PRN Seroquel noted to be calmer. On 4/14/26 at 1:18 p.m., remained 1:1 for this shift. On 4/14/26 at 10:18 p.m., [R2] busy this shift wandering, moving furniture.
Had 1:1 starting at 4:00 p.m. to 10:00 p.m. On 4/15/26 at 4:14 a.m., slept almost entire shift, no behaviors.
Continue frequent checks. On 4/15/26 at 1:45 p.m., [R2] walked around courtyard, attempting to break off branches and flowers.
Recreation staff attempted to distract and remove from [NAME] and tried to sneak a peak down back of pants as there was a foul odor [R2] grabbed staff's fingers and said, If you touch me again, I'll break every finger on your hand.
Proceeded to squeeze hand and lead recreation staff with him for approximately 15 seconds then let go. On 4/16/26 at 12:05 p.m., [R2] seen by psychiatric provider.
New orders received: discontinue scheduled Seroquel (no need for two antipsychotics), change Zyprexa to 10 mg po every a.m. and 10 mg po every 5:00 p.m. (when available), add Zyprexa 5 mg po every six hours PRN for agitation or aggression. On 4/16/26 at 9:21 p.m., No behaviors this shift.
Wife here for activity and had 1:1 from 4:00 p.m. to 9:00 p.m. On 4/16/26 at 5:37p.m., Late entry 4/14/26.
Wife returned writer's call.
Discussed possible discharge planning maybe needed for resident related to recent behaviors or an inpatient behavioral hospital stay.
Writer asked if family would be able to come and be with resident.
Wife does not live locally and indicated family would not be able to come. On 4/17/26 at 22:19 p.m., No noted aggressive behaviors. He did have some unrecognizable type of conversation, wandering, but no noted issues. On 4/18/26 and 4/19/29, no behaviors noted. On 4/19/26 at 1:28 p.m., Walking around, wandering around unit today.
Typical baseline.
Has walked around peer he had incident on 4/10/26. [R2] did not appear fearful when he has walked by peer or when peer walked by him.
Did not appear to remember incident or other resident involved. On 4/20/26 at 9:39 p.m., Beginning of shift [R2] had increased agitation and not able to redirect. He received Zyprexa 5 mg which was effective. On 4/23/26 at 9:25 p.m., [R2] wandering in south and north units and into other resident rooms, rearranging furniture.
Used redirection, positive reinforcement and distractions.
Confused and not aggressive responses. On 4/24/26 at 10:16 p.m., [R2] was very agitated, took food from another resident's plate, walked around with the dinner plate and silverware, very hard to redirect.
Currently 1:1 with staff person. On 4/26/26 at 12:46 p.m., Required more supervision as he wandered, unable to stay on task, easily redirectable but required frequent redirection. R2's psychiatric visit progress note dated 1/22/26, identified [R2] as having a lot of behaviors, not sleeping well, seemed to have his days and night
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.