Inspection Reports for
Mercy Caregivers Of Minnesota
556 84Th Avenue Ne, Spring Lake Park, MN 55432, MN, 55432
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Inspection Report — Jun 20, 2024
Routine
Date: Jun 20, 2024
Visit Reason
MDH assisted living licensing survey (full survey completed 2024-06-20). Follow-up survey on 2024-09-09 verified orders from the June 20, 2024 survey were corrected and the facility was in substantial compliance.
Findings
Full MDH assisted living licensing survey issued 12 state correction orders addressing staffing and posting, food code violations, employee records, emergency preparedness and missing-person policy, multiple fire- and egress-related hazards (smoke alarms, ashtray practice, and inadequate egress window openings), missing statutory contract language about designation of a representative, late nursing reassessments, and medication management/setup issues. A fine of $3,000.00 was assessed.
Deficiencies (12)
0470 144G.41 Subdivision 1 Minimum requirements: The facility did not develop and post a required written staffing plan or schedule and failed to ensure periodic evaluation of staffing appropriateness.
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; specific food-code violations documented in the Food and Beverage Establishment Inspection Report.
0650 144G.42 Subd. 8 Employee records: An employee record (ULP-C) lacked a current job description including supervision, required health screening documentation, and the required background study documentation.
0680 144G.42 Subd. 10 Disaster planning and emergency preparedness: The emergency preparedness plan lacked required content (tracking staff/residents, evacuation procedures/locations, medical documentation continuity, volunteer integration, role under federal waivers), had no documented twice-annual testing/exercises, and the missing-resident policy was not reviewed/documented quarterly.
0780 144G.45 Subd. 2 (a) (1) Fire protection and physical environment: Smoke alarms were not interconnected so that actuation of one alarm would cause all alarms in the dwelling unit to sound.
0800 144G.45 Subd. 2 (a) (4) Fire protection and physical environment: The facility failed to maintain the physical environment in a state of good repair and had a combustible ashtray practice (cookie tin with water) creating a fire hazard.
0810 144G.45 Subd. 2 (b)-(f) Fire protection and physical environment: The facility lacked a fire safety and evacuation plan with required content and did not provide required employee training and evacuation drills.
0820 144G.45 Subd. 2 (g) Fire protection and physical environment: Egress windows in resident bedrooms did not meet minimum openable height and openable area requirements, creating an immediate egress hazard.
0950 144G.50 Subd. 3 Designation of representative: Resident R1's contract did not include the required statutory notice on a document separate from the contract and did not document a designated representative or declination on the separate form.
01620 144G.70 Subd. 2 (c-e) Initial reviews, assessments, and monitoring: The RN did not complete the required resident reassessment within 14 days of admission for R1 and ongoing reassessments exceeded 90 days (one reassessment was dated 91 days after the prior assessment).
01730 144G.71 Subd. 5 Individualized medication management plan: R1's record lacked an individualized medication management plan documenting medication storage, persons responsible for monitoring supplies/refills, procedures for notifying a licensed nurse when problems occur, and resident-specific medication documentation requirements.
01770 144G.71 Subd. 9 Documentation of medication setup: Medication setup documentation for R4 did not include required elements at the time of setup (name of medication, quantity of dose, times to be administered, and route of administration).
Report Facts
total_fines_assessed: 3000
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