Jones Harrison Residence
Jones Harrison Residence in MINNEAPOLIS, MN — inspection on January 9, 2026.
Found 10 citations. 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
guidelines to follow for what diagnoses are appropriate, confirming anxiety was not an appropriate
cognitive impairment.R108's EMR contained an order, dated 1/6/26, for lorazepam (an antianxiety
for lorazepam 0.5mg every 2 hours as needed for 14 days, dated 12/28/25 and discontinued on 1/6/26.R108's medication administration records indicated R108 had received 6 doses of as needed lorazepam in December 2025 and 1 dose in January 2026 between 1/1/26 and 1/5/26.R108's EMR to include progress notes, medication and treatment administration records for December 2025 and January 2026 and behavior task documentation lacked documentation to justify the need for scheduled lorazepam every 2 hours.
The EMR further lacked evidence that non-pharmacological interventions had been attempted prior to as needed lorazepam administration.
During an interview on 1/8/26 at 10:25 a.m., nursing assistant (NA)-C stated she didn't know R108 to have much anxiety, stating maybe once and awhile. NA-C stated if R108 seemed anxious, she often wanted to see her daughter or be left alone.
During an interview on 1/8/26 at 9:58 a.m., nurse manager and registered nurse (RN)-B stated it would be expected that R108's behaviors and non-pharmacological intervention attempts would be documented on the medication and treatment administration record, confirming there was no documentation of resident behaviors nor non-pharmacological interventions in the month of December or January.A facility policy titled Psychopharmacologic Drug Use, revised 5/2025, indicated:1.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: Without adequate monitoring; or without adequate indications for its use.2. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior, including antipsychotic medications and antianxiety medications. 3. If not clinically contraindicated, multiple non-pharmacological approaches have been attempted but did not relieve the medical symptoms which are presenting a danger or significant distress; and/or GDR was attempted, but clinical symptoms returned.4.
Documentation in the resident's medical record will indicate the rationale for the use of psychotropic medication.
The rationale must be based on sound risk/benefit analysis of the resident's symptoms and potential adverse effects of the drug.
245460 01/09/2026
Jones Harrison Residence 3700 Cedar Lake Avenue Minneapolis, MN 55416
harm while the situation is being investigated.External Reporting Procedure1.
The Administrator
245460 01/09/2026
Jones Harrison Residence 3700 Cedar Lake Avenue Minneapolis, MN 55416
During an interview on 1/9/26 at 8:45 a.m., RN-D stated she recalled reading a progress note regarding R81 reporting an allegation of sexual abuse and that the camera in her room was reviewed by family. RN-D stated she would have expected that to be reported to the DON immediately to start investigating what happened.During an interview on 1/9/26 at 9:52 a.m., the director of social services (DSS)-A stated she was aware R81 had made allegations of sexual abuse, but she was just made aware of the allegation reported in December. DSS-A stated it would be expected that staff investigate to gather as much information as possible and if staff can't prove it didn't happen it should be reported. DSS-A stated the allegation made in December should have immediately been reported to the supervisor and the DON for investigation.
During an interview on 1/9/26 at 10:50 a.m., the DON confirmed the allegation of sexual abuse reported by R81 in December was not reported to her and she would have expected it to be so that it could have been thoroughly investigated. A facility policy, titled Vulnerable Adult - Abuse Prohibition Plan, revised 10/2024, indicated:During the shift that the alleged abuse/neglect, unexplained injury or suspected crime is first observed, a mandated reporter/covered individual will immediately make an initial report to their supervisor, after securing the resident's safety.
Steps must be taken to ensure that no resident in the facility remains in danger of maltreatment, including medical intervention if needed.If potential maltreatment is suspected or unknown, the Supervisor will immediately report to the Administrator and/or designee Director of Nursing.Immediate steps are taken to protect the vulnerable adult from harm while the situation is being investigated.The Building Charge, Nurse Manager, Director of Nursing, or Administrator will immediately institute an internal investigation of the reported allegation or incident.
The investigation may include but not limited to:a.
Interviews of staff and written statements from staffb.
Resident interviewsc.
Resident Representative interviewsd.
Witness interviews and written statements of incidente.
Care observationsf.
Environmental review g.
Resident health status/Medical record review
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Jones Harrison Residence 3700 Cedar Lake Avenue Minneapolis, MN 55416
During a
R18 smiled but did not answer questions. R18's quarterly MDS assessment, dated 11/1/25, identified R18 had severely impaired cognition.
Diagnoses included dementia (significant loss of memory, thinking and reasoning skills), atrial fibrillation (an irregular and often rapid heart rhythm), dysphagia (difficulty swallowing), chronic pain and hemiplegia (paralysis affecting one side of the body).
The MDS contained section O which contained a section hospice care which was marked no indicating R18 did not receive hospice services. R18's orders, printed 1/9/26, included the following order:-ok for hospice to evaluate, treat and accept with a start date of 8/1/24-call hospice in case of an emergency [number listed] with a start date of 10/29/25 R18's electronic medical record (EMR) contained a section titled special instructions which was listed R18's name, allergies and code status which indicated [name of hospice] hospice. R18's care plan, printed 1/6/26, indicated R18 was enrolled in hospice with a potential for knowledge deficit of hospice philosophy/program and an expected physical and cognitive decline which was last revised on 11/5/24.
The care plan did contain additional information regarding R18 and hospice and interventions.
During an interview on 1/7/26 at 9:20 a.m., licensed practical nurse (LPN)-A verified R18 was on hospice.
During an interview on 1/8/26 at 10:57 a.m., director of MDS (MDS)-A verified R18 was on hospice. MDS-A indicated the last MDS was coded incorrectly and should have indicated R18 was on hospice. MDS-A stated a modification for R18's quarterly MDS assessment on 11/1/25 had been submitted after review.
During an interview on 1/9/26 at 11:10 a.m., director of nursing (DON) stated the accuracy of MDS was important and it helps ensure staffing levels are appropriate and appropriate cares are provided to all residents. A facility policy titled MDS/Care Plan Process/Resident Assessment, revised 10/21/25.
Under the section Accuracy of Assessments, the document indicated the assessment must represent an accurate picture of the resident's status during the observation period of the MDS.
245460 01/09/2026
Jones Harrison Residence 3700 Cedar Lake Avenue Minneapolis, MN 55416
During observation and interview on 1/5/26 at 4:25 p.m., R90 had fingernails approximately 1/4 inch long with dark matter underneath them. R90 looked down at his nails and stated, they do need to be trimmed and cleaned.
During a second observation on 1/8/25 at 10:34 a.m., R90's nails continued to extend past his fingertips with dark matter still underneath all of his nails.
During an interview on 1/8/26 at 10:25 a.m., nursing assistant (NA)-C stated it was the expectation that residents receive nail care whenever it is needed but also on bath days. NA-C also stated every morning facility staff should be assisting residents with washing their hands and ensuring their nails are clean.
During an interview on 1/9/26 at 8:21 a.m., nurse manager and registered nurse (RN)-B stated it would be expected that staff keep resident's nails clean and provide nail care on bath days. RN-B confirmed there were no notes in the electronic medical record regarding R90's nail care being completed. A facility policy on Activities of Daily Living was not received.
245460 01/09/2026
Jones Harrison Residence 3700 Cedar Lake Avenue Minneapolis, MN 55416
believe that R108 needed antianxiety medication every 2 hours or even scheduled every 12 hours and
have expected that either the floor nurses or the nurse manager question the lorazepam order and
0.5mg every 2 hours as needed to scheduled every 2 hours.A facility policy titled Medication Administration-General Guidelines, dated [DATE], indicated, If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnoses or conditions, the nurse calls the provider pharmacy for clarification prior to the administration of the medication or if necessary contacts the MD/NP [doctor/nurse practitioner] for clarification.
This interaction with the pharmacy and/or MD/NP and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate.
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Jones Harrison Residence 3700 Cedar Lake Avenue Minneapolis, MN 55416
RN-A verified there were no non-pharmacological interventions offered to R4 prior to administration of
would be that non-pharmacological interventions would be offered and documented prior to the use of
residents have the right for appropriate pain evaluation and pain medication.
The policy indicated non-pharmacological interventions research supports physical activity and exercise as a part of most treatment programs for chronic pain.
245460 01/09/2026
Jones Harrison Residence 3700 Cedar Lake Avenue Minneapolis, MN 55416
During an interview on 1/5/26 at 1:56 p.m., R2 was observed lying in bed. R2 was nonsensical and repeated self.
During an interview on 1/8/26 at 12:15 p.m., R2 was observed lying in bed. R2 asked what was for lunch and then said goodbye as she waiting for her lunch and declined to talk any further.
During an interview on 1/8/26 at 12:20 p.m., nursing assistant (NA)-B stated if a resident had PTSD and had triggers it would be on their care plan. NA-B stated they do not believe that R2 has PTSD. NA-B stated there are no known triggers for R2.
During an interview on 1/8/26 at 12:30 p.m., licensed practical nurse (LPN)-B stated if a resident had a diagnosis of PTSD, that would be listed on the care plan along with any triggers. LPN-B reviewed R2's diagnoses and verified R2 had a diagnosis of PTSD and stated this information along with any triggers should be on the care plan.
During an interview on 1/8/26 at 12:36 p.m., director of social services (DSS)-A stated it's important to gather all the information possible either form the resident, medical records, family, other providers to help not retraumatize a resident when they have a history of trauma or PTSD. DSS-A stated it is important to try to identify triggers and communicate this information to all the staff.
During a follow up interview on 1/9/26 at 10:25 a.m., SSD-A verified she was able to review R2's medical record. SSD-A verified there was not a trauma care plan prior to interview yesterday and should have been. SSD-A reviewed the initial assessment completed that did not identify triggers, reviewed therapist notes that did identify trauma history and how that could be related to current behaviors. SSD-A stated she updated R2's care plan to reflect a trauma history. SSD-A stated it is important to gather all this information from all sources to do their best to not retrigger a resident, even if they can't identify a trigger, and avoid further trauma.
During an interview on 1/9/26 at 11:09 a.m., director of nursing (DON) stated a residents trauma history needs to be assessed and care planned so staff are aware of the trauma, so they don't retraumatize residents. A facility policy titled Trauma Informed Care, reviewed 1/22/25, identified the goal of trauma informed care is to ensure an environment that is safe and sensitive and to ensure the available of trained professionals.
245460 01/09/2026
Jones Harrison Residence 3700 Cedar Lake Avenue Minneapolis, MN 55416
Review of the staff schedules and time sheets indicated the facility had the appropriate licensed 24-hour nursing coverage and RN hours as required.
During interview on 1/6/26 at 1:59 p.m., administrator stated she was responsible for submitting the staffing data and was not surprised the report triggered for the missing RN and licensed nursing hours.
She stated she attempted to submit the August data and stayed late to complete the submission; however, she encountered technical issues and it didn't go through.
During an interview on 1/9/26 at 11:04 a.m., the director of nursing (DON) stated the administrator was in charge of submitting the PBJ report and she didn't have anything to do with submitting it.
The DON stated she knew the administrator was having troubles submitting the report for August.
The DON stated the facility as a registered nurse in the building at all times so knows that the report wasn't accurate.
The facility Payroll Based Journal - Error Report and XML Files policy revised 1/25, indicated administrators or designees will log onto the CMS website and enter data, check validation report, and verify the submitted report is accurate and complete.
During an interview on 1/8/25 at 2:29 p.m., the infection preventionist (IP) stated she was unaware that damp laundry was being left in the washing machine overnight after being washed.
The IP stated she thought this practice could be improved and not something she would do at home but was unsure what the infection control risk was.
The facility's Linen Handling to Prevent and Control Infection Transmission policy, dated 11/11/24, was reviewed and did not include direction on whether laundry could be left in the machine overnight.
245460 01/09/2026
Jones Harrison Residence 3700 Cedar Lake Avenue Minneapolis, MN 55416