3 Reports
Inspection Report — Apr 17, 2025
Routine
Date: Apr 17, 2025
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MDH assisted living licensing survey.
Findings
The Minnesota Department of Health completed an assisted living licensing survey and issued 12 state correction orders. Orders addressed facility licensing and use of space, food service/Minnesota Food Code violations, required postings and grievance information, staff records and orientation/competency, delegation and documentation of treatments/therapy, service plan content, arbitration language, and supportive device documentation; no immediate fines were assessed.
Deficiencies (12)
0100 144G.10 Subdivision 1 License required: This Minnesota requirement is not met as evidenced by the licensee allowing use of facility space by a third‑party therapy vendor that rents space and accesses through common areas, which the evaluator found could affect all residents.
0480 144G.41 Subdivision 1 Minimum requirements; required food services: This Minnesota requirement is not met as evidenced by food being prepared and served in ways that did not meet the Minnesota Food Code (see Food and Beverage Establishment Inspection Report dated April 15, 2025).
0550 144G.41 Subd. 7 Resident grievances; reporting maltreatment: This Minnesota requirement is not met as evidenced by the licensee's grievance posting lacking required contact names, telephone numbers, email information and required ombudsman reporting contacts.
0640 144G.42 Subd. 7 Posting information for reporting suspected c: This Minnesota requirement is not met as evidenced by the 911 emergency number not being posted near phones at the main entrance and nurse's station.
0650 144G.42 Subd. 8 (a) Staff records: This Minnesota requirement is not met as evidenced by one employee record (ULP-C) lacking documented competency evaluations for medication administration and delegated treatments.
0980 144G.51 ARBITRATION: This Minnesota requirement is not met as evidenced by the resident agreement containing a choice of venue provision specifying arbitration would occur in the county where the community is located.
01420 144G.62 Subd. 2 Delegation of assisted living services: This Minnesota requirement is not met as evidenced by unlicensed personnel providing care before the RN had ensured and documented required training and competency demonstrations.
01460 144G.63 Subdivision 1 Orientation of staff and supervisors: This Minnesota requirement is not met as evidenced by at least one recently hired unlicensed staff member (ULP-F) providing direct care without documented completion of required assisted living orientation.
01470 144G.63 Subd. 2 Content of required orientation: This Minnesota requirement is not met as evidenced by multiple employees' records (including CNS-B, ULP-C, ULP-G) lacking required orientation content such as an overview of assisted living statutes, complaint reporting, and advocacy contact information.
01650 144G.70 Subd. 4 (f) Service plan, implementation and revisions to: This Minnesota requirement is not met as evidenced by R5's service plan failing to include assistance with R5's lymphedema pumps as ordered and provided by staff three times daily.
01950 144G.72 Subd. 4 Administration of treatments and therapy: This Minnesota requirement is not met as evidenced by residents (R2, R5) lacking written, specific RN instructions in the record for treatments (blood glucose parameters, lymphedema pumps/wraps) and by unlicensed staff (ULP-D, ULP-F) lacking RN training/competency documentation for those therapies.
02310 144G.91 Subd. 4 (a) Appropriate care and services: This Minnesota requirement is not met as evidenced by R5's vertical transfer pole lacking manufacturer installation/documentation and no documented supportive device assessment or staff education on correct use.
Report Facts
fines assessed: 0
Inspection Report — May 5, 2022
Routine
Date: May 5, 2022
Visit Reason
MDH assisted living licensing survey.
Findings
Routine MDH assisted living licensing survey issued 19 correction orders addressing disclosure and resident rights, employee records and training, TB prevention and disaster preparedness, fire protection and evacuation, resident contracts and assessments, medication management and documentation, and treatment/therapy orders. No immediate fines were assessed.
Deficiencies (19)
0430 144G.40 Subd. 2 Uniform checklist disclosure of services: The licensee failed to provide a copy of the uniform checklist disclosure of services (UDALSA) with the required content for four of nine residents (R1, R3, R6, R9).
0450 144G.41 Subdivision 1 Minimum requirements: The licensee failed to provide the Assisted Living Bill of Rights and obtain written acknowledgement for four of nine resident records reviewed (R1, R3, R6, R9).
0650 144G.42 Subd. 8 Employee records: The licensee's employee record for ULP-C lacked a current job description, as required.
0660 144G.42 Subd. 9 Tuberculosis prevention and control: The licensee failed to document required TB education for three employees (RN-B, ULP-C, ULP-E) per the facility TB prevention program.
0680 144G.42 Subd. 10 Disaster planning and emergency preparedness: The facility emergency preparedness plan lacked required content including risk assessment, subsistence planning, evacuation/shelter plans, communications and written transfer/relocation agreements.
0810 144G.45 Subd. 2 (b)-(f) Fire protection and physical environment: The licensee's fire safety and evacuation plans and training were incomplete (no identification of unique resident evacuation needs, training frequency not met, and no resident training documentation).
0900 144G.50 Subdivision 1 Contract required: The licensee failed to execute or maintain current resident contracts for four of eight residents reviewed (R1, R3, R6, R9) and had multiple contract versions in use.
01290 144G.60 Subdivision 1 Background studies required: Employee records for ULP-C and ULP-E lacked documented background studies affiliated under the new license holder.
01460 144G.63 Subdivision 1 Orientation of staff and supervisors: RN-B's employee record lacked evidence of completion of orientation to assisted living licensing requirements before providing services.
01620 144G.70 Subd. 2 (c-e) Initial reviews, assessments, and monitoring: The licensee failed to ensure nursing reassessment and monitoring after residents' falls for two residents (R2, R3), including lack of documented post-fall monitoring and lack of physician notification documentation.
01640 144G.70 Subd. 4 (a-e) Service plan, implementation and revisions to: The licensee failed to revise R6's service plan to reflect provision of pressure-relief moon boots ordered by hospice (task present on caregiver sheets but missing from the evaluation/service plan).
01650 144G.70 Subd. 4 (f) Service plan, implementation and revisions to: Multiple resident service plans lacked required content including fees for services, identification of staff categories providing services, monitoring schedules, contingency actions, and emergency contact information (R1, R2, R3, R5, R6, R7).
01700 144G.71 Subd. 2 Provision of medication management services: Medication management assessments did not document review of indications, side effects, contraindications or adverse reactions for all medications for four residents receiving medication management (R1, R2, R5, R6).
01760 144G.71 Subd. 8 Documentation of administration of medication: Multiple medication documentation and transcription issues were found, including missing PRN follow-up documentation (R6), transcription errors and missing prescriber orders on MARs (R5, R6), and staff documenting administration prior to giving medications (R2).
01790 144G.71 Subd. 10 Medication management for residents who will: The licensee's written procedure for providing medications for unplanned time away did not include required delegation specifics, labeling, documentation procedures, RN notification, or return of unused medication instructions.
01820 144G.71 Subd. 13 Prescriptions: Resident records for R5 and R6 lacked current signed prescriber orders for various managed medications.
01940 144G.72 Subd. 3 Individualized treatment or therapy management: The licensee failed to maintain individualized treatment/therapy management records for treatments provided (e.g., application/removal of TED stockings) for R1.
01950 144G.72 Subd. 4 Administration of treatments and therapy: The RN had not documented training/competency for unlicensed staff (ULP-E) delegated to apply circulatory/pressure devices and records lacked resident-specific written instructions for delegated treatments (R3, R6).
01970 144G.72 Subd. 6 Treatment and therapy orders: The licensee did not have current written treatment orders in the resident record at the time of survey for R1's TED stockings (orders were later obtained May 3, 2022).
Report Facts
immediate_fines_assessed: 0
Inspection Report — Sep 2, 2021
Complaint Investigation
Date: Sep 2, 2021
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MDH compliance investigation; no maltreatment alleged.
Complaint Details
HL30228001C | Finding: not stated | Compliance review of the provider's care; no maltreatment alleged.
Findings
Finding not stated. Two correction orders were issued addressing application for licensure documentation and infection control failures, including inconsistent PPE/eye protection use and inadequate staff and resident screening.
Deficiencies (2)
0130 144G.12, Subd. 1 Application for Licensure: The facility failed to include independent living resident capacity during the transition to an assisted living license; the assisted living license indicated a capacity of 42 while 72 residents lived at the facility.
0510 144G.41, Subd. 3 Infection control program: The facility failed to establish and maintain an effective infection control program for COVID-19; staff did not consistently wear required PPE including eye protection and the facility did not perform required staff and resident screening.
Report Facts
residents_receiving_services: 72
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