3 Reports
Inspection Report — Sep 11, 2025
Routine
Date: Sep 11, 2025
Visit Reason
MDH assisted living licensing survey.
Findings
Five correction orders were issued for food service practices, infection control, fire protection and evacuation planning, and medication storage; total fines assessed $1,000.
Deficiencies (5)
0480 144G.41 Subdivision 1 Subd. 1a (a-b) Minimum requirements; required food services: The licensee failed to ensure food was prepared and served according to the Minnesota Food Code, as documented in the Food and Beverage Establishment Inspection Report.
0510 144G.41 Subd. 3 Infection control program: Staff failed to follow infection control practices during resident care, including using the same gloves to feed multiple residents and not changing gloves or performing hand hygiene during catheter care and personal cares.
0775 144G.45 Subd. 2. (a) Fire protection and physical environment: The facility had controlled exit door locks without documented operating procedures and a non-functioning tamper switch on a rear wall hydrant, indicating noncompliance with the state fire code.
0810 144G.45 Subd. 2 (b-f) Fire protection and physical environment: The fire safety and evacuation plan did not include required resident-specific procedures or documentation of resident training and drills.
01880 144G.71 Subd. 19 Storage of medications: Medication refrigerator temperatures were not consistently monitored or recorded for two medication refrigerators, leaving gaps in daily temperature logs required to ensure manufacturer-recommended storage temperatures.
Report Facts
fine assessed (tag 0510): 500
fine assessed (tag 0775): 500
total fines assessed: 1000
Inspection Report — Nov 21, 2023
Complaint Investigation
Date: Nov 21, 2023
Visit Reason
MDH complaint investigation of alleged sexual abuse and neglect.
Complaint Details
HL285457007M | Finding: Substantiated, facility responsibility | A staff member allegedly sexually abused the resident by inappropriately touching her, causing bruising to the thighs and peri-vulvar area, and the facility neglected the resident by failing to assess, investigate, and implement interventions for repeated inner-thigh bruising.
Findings
Maltreatment substantiated, facility responsibility. One correction order was issued addressing freedom from maltreatment.
Deficiencies (1)
02360 144G.91 Subd. 8 Freedom from maltreatment: The facility failed to ensure one resident reviewed was free from maltreatment. MDH determined maltreatment occurred and the facility was responsible.
Inspection Report — Oct 14, 2021
Routine
Date: Oct 14, 2021
Visit Reason
MDH assisted living licensing survey; includes a follow-up survey on 2022-01-18 that determined not all orders from the October 14, 2021 evaluation were corrected.
Findings
The survey resulted in 11 correction orders addressing staffing and posting of staff schedules, food preparation/Food Code violations, infection control during medication administration, failure to post the facility license, absence of quality management activities, incomplete employee records, incomplete emergency preparedness planning, missing resident contracts, missing or late nursing assessments, and lack of electronic-monitoring visitor notice; total fines assessed were $500.
Deficiencies (11)
0470 144G.41 Subdivision 1 Minimum requirements: The facility lacked a written staffing plan and did not post a staffing plan or current staff schedule at the facility entrances to ensure appropriate staffing levels to meet residents' needs.
0480 144G.41 Subd 1 (13) (i) (B) Minimum requirements: The licensee failed to ensure food was prepared and served according to the Minnesota Food Code; see the Food and Beverage Establishment Inspection Report (10/11/2021) for specific Food Code deficiencies.
0510 144G.41 Subd. 3 Infection control program: Staff used gloved hands to reach into medication bottles and poured residents' pills into gloved hands when administering medications, which is not consistent with appropriate infection control practices.
0570 144G.42 Subd. 1 Display of license: The facility failed to post the current assisted living license at the main entrances; the license was found in the nursing office on a shelf rather than posted at the entrances.
0580 144G.42 Subd. 2 Quality management: The licensee had no documented quality management project or ongoing QA documentation appropriate to the size of the provider and relevant to services provided.
0650 144G.42 Subd. 8 Employee records: Employee records for multiple unlicensed personnel lacked documentation of annual performance reviews that identify areas of improvement and lacked current job descriptions.
0680 144G.42 Subd. 10 Disaster planning and emergency preparedness: The written emergency preparedness plan lacked required content (comprehensive hazard/vulnerability assessment, population description, communication plan, subsistence needs, staff/resident tracking, training and testing requirements, and signed agreements) and was not prominently posted.
0900 144G.50 Subdivision 1 Contract required: The licensee failed to develop and execute a written assisted living contract with the required content for at least one resident (transfer from a sister facility) prior to or at start of services.
01610 144G.70 Subd. 2 Initial reviews, assessments, and monitoring: The registered nurse did not complete an initial comprehensive nursing assessment for a transferred resident (R5) when services began at this facility.
01620 144G.70 Subd. 2 Initial reviews, assessments, and monitoring: The registered nurse failed to complete required follow-up reassessments within 14 days of initiation of services for two residents (R1 and R5).
03090 144.6502, Subd. 8 Notice to Visitors: The facility did not post the statutory notice at each entrance advising that electronic monitoring devices may be present to record persons and activities.
Report Facts
fines_assessed_total: 500
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