Victory Health & Rehabilitation Center

During an interview on 1/13/26 at 8:22 a.m., R3's representative (RR)-A stated he was not invited to a recent care conference, and he had concerns about communication with the facility.

R25 R25's quarterly MDS dated [DATE], identified intact cognition, no adverse behaviors, and was independent with wheelchair mobility.

R25's medical record identified the most recent care conference was held on 8/19/25, and no additional care conferences were held.

R25 had an additional quarterly MDS completed on 11/9/25, There was no indication in the progress notes or medical record of any care conference held at the time of this assessment.

During an interview on 1/12/26 at 1:24 p.m., R25 stated he was not invited to a recent care conference, and he would have wanted one to bring up some concerns.

R30 R30's admission MDS dated [DATE], identified R30 had moderate impaired cognition, diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and major depressive disorder. In addition, MDS indicated R30 communicated needs, and understood direction and conversation.

Furthermore, MDS indicated R30 exhibited no adverse behaviors.

R30's medical record lacked documentation of any care conferences.

During interview on 1/15/26 at 1138 a.m., the director of nursing (DON) verified the medical record did not have a care conference documented at any time for R30.

The expectation for care conferences were to be completed within the first 48 hours of admission, quarterly and as necessary.

245544 01/15/2026

Victory Health & Rehabilitation Center 512 49th Avenue North Minneapolis, MN 55430

F 0553 R14

diabetes, and legal blindness. It further indicated R14 required partial assistance with most ADL's and

R14's medical record indicated the most recent care conference was held on 8/18/25. R14's medical record showed no additional care conferences since 8/18/25.

R14's progress notes (since admission on [DATE]), lacked documentation that a care conference had been completed.

During interview on 1/12/2026 at 2:12 p.m., R14 stated he had not had a care conference since being admitted to the facility.

During interview on 1/15/25 at 9:27 a.m., the DON stated the social worker was responsible for completing care conferences and they should be completed upon admission (within 48 hours) and then quarterly.

The DON verified R14's last care conference was on 8/18/25, R25's was on 8/19/25, and R3's was on 8/20/25. He stated all 3 residents should've had another care conference in December and he expected care conferences to be completed quarterly following admission.

A facility policy titled care conferences dated 9/2013, did not address how often care conferences should be completed.

245544 01/15/2026

Victory Health & Rehabilitation Center 512 49th Avenue North Minneapolis, MN 55430

provide resident education and update the provider for 1 of 1 resident (R33) who routinely refused

identified intact cognition, no adverse behaviors, was independent with meals and hygiene and had a diagnosis of chronic systolic (congestive) heart failure (CHF).R33's care plan dated 11/8/25, identified he was on a diuretic medication related to CHF.

Interventions included administer diuretic medications as ordered by physician and monitor/document/report adverse reactions to diuretic therapy.R33's orders identified start date of 2/20/25, for bumetanide 1 milligram (mg) tablet, give two tablets two times a day related to CHF.R33's Medication Administration Record (MAR) dated 11/1/25 through 11/30/25, identified bumetanide was refused 45 out of 60 opportunities.

The MAR dated 12/1/25 through 12/31/25, identified bumetanide was refused 55 out of 62 opportunities.

The MAR dated 1/1/26 through 1/15/26, identified bumetanide was refused 26 out of 29 opportunities.R33's nursing progress notes dated 11/1/25 through 1/15/26, lacked documentation of rationale for the refusal or that the risks and consequences had been discussed.R33's nurse practitioner's visit noted dated 11/12/25, and physician's visit note dated 12/1/25, lacked documentation of diuretic refusal.

During an interview on 1/14/26 at 7:40 a.m., trained medication aide (TMA)-B stated R33 refused his diuretic and if a medication was refused the TMA should update the nurse.During an observation on 1/14/26 at 8:20 a.m., TMA-B prepared R33's morning medications, minus the bumetanide and brought the medications into his room.

During an interview on 1/14/26 at 9:47 a.m., R33 stated he had not wanted his diuretic because it made him go to the bathroom too often.During an interview on 1/14/26 at 9:55 a.m., licensed practica nurse (LPN)-B stated a diuretic was an important medication and if a resident refused that medication more than one to three times, the providers should be updated. LPN-B stated that it would not necessarily be documented in a nursing progress note if a provider was updated on a medication refusal and to check the provider's notes instead.

During an interview on 1/15/26 at 9:15 a.m., Medical Doctor (MD)-B stated if a concern about a medication was brought up to the provider group and it would be in the visit notes. MD-B declined to acknowledge awareness of R33 refusing diuretic medication, however acknowledged there was no documentation his notes or the nurse practitioner notes. MD-B stated if a medication was refused the patient should know the risk and benefits and the provider should be updated if the resident had a change in condition.

During an interview on 1/15/26 at 12:39 p.m., the director of nursing (DON) stated medications should be given as ordered for safety purposes and to help the residents regain health. A diuretic was a high-risk medication, and residents had the right to refuse, however, nursing should have provided and documented education on risks and consequences of diuretic refusal.The facility's Medication Administration policy dated 4/2018, identified if a drug was refused the individual administering the medication shall be coded as indicated on the MAR space provided for that drug and dose.

Additionally, as required or indicated for a medication the individual administering the medication would record in the resident's medical record any complaints or symptoms for which the drug was administered and any results achieved and when those results were observed.

proper containers.

245544 01/15/2026

Victory Health & Rehabilitation Center 512 49th Avenue North Minneapolis, MN 55430