Deficiencies (over last year)
Deficiencies (over last year)
27 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
592% worse than Minnesota average
Minnesota average: 3.9 deficiencies/year
Deficiencies per year
28
21
14
7
0
Inspection Report
Follow-Up
Census: 50
Deficiencies: 27
Date: Mar 15, 2023
Visit Reason
Follow-up evaluation to determine if orders from the January 13, 2023 evaluation were corrected.
Findings
The facility was found to be in substantial compliance during the follow-up evaluation. The original inspection identified multiple deficiencies including staffing, infection control, medication management, emergency preparedness, resident record keeping, and fire safety.
Deficiencies (27)
Failed to show managerial officials understood applicable statutes and rules and failed to develop and implement required policies and procedures.
Failed to develop and implement a staffing plan including posting daily work schedules and conducting evaluations twice a year.
Failed to ensure food was prepared according to Minnesota Food Code.
Failed to maintain an effective infection control program including improper glove use and medication administration.
Failed to maintain current employee records including competency evaluations and background studies.
Failed to have a written emergency disaster plan with required content and failed to post emergency plan prominently.
Failed to protect resident personal health and medical information from unauthorized disclosure.
Failed to include discharge summary in resident record for discharged resident.
Failed to provide smoke alarms immediately outside sleeping areas in two-bedroom apartments and failed to interconnect smoke alarms.
Failed to maintain physical environment in good repair including fire sealant penetrations and sprinkler head maintenance.
Failed to develop and maintain fire safety and evacuation plans and provide required training to residents and employees.
Failed to provide written notice with required content for emergency relocation and failed to notify Office of Ombudsman for Long-Term Care.
Failed to provide notice to Office of Ombudsman for Long-Term Care or Mental Health and Developmental Disabilities of curtailment and transfers prior to notifying residents.
Failed to submit and receive background studies for employees under current license.
Failed to provide delegated training by registered nurse to unlicensed personnel for use of external female catheter.
Failed to ensure staff completed orientation to assisted living licensing requirements before providing services.
Failed to ensure staff completed required annual training including review of assisted living bill of rights.
Failed to conduct resident reassessment and monitoring within required timeframes.
Failed to revise service plan based on change of service and failed to obtain resident or representative signature on service plan.
Failed to ensure registered nurse trained unlicensed personnel in medication administration and verified competency.
Failed to document medication administration accurately including insulin pen priming and medication errors.
Failed to securely store medications and permit only authorized personnel access; powders and creams stored improperly.
Failed to maintain medications with original prescription labels and failed to label time sensitive medications with date opened.
Failed to document disposition of medications for discharged residents including medication name, strength, prescription number, and quantity.
Failed to ensure awake staff physically present 24/7 in secured dementia care units to respond to resident requests.
Failed to provide policies and procedures for assisted living with dementia care to residents or representatives at move-in.
Failed to provide written or electronic description of dementia care training program to residents, families, or others upon request.
Report Facts
Residents present: 50
Residents receiving dementia care: 47
Fines assessed: 9500
Deficiency counts: 30
Temperature: 166.6
Temperature: 169
Temperature: 166
Temperature: 40
Temperature: 39
Temperature: 171
Days between nursing assessments: 166
Days between nursing assessments: 110
Days between nursing assessments: 134
Days between nursing assessments: 139
Days between nursing assessments: 188
Days medication open: 43
Days medication open: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Casey DeVries | Supervisor, Health Regulation Division, State Evaluation Team | Signed follow-up evaluation letter |
| Anthony Guerrieri | Head Cook | Certified Food Protection Manager named in food inspection report |
| Jeff Johanson | Unknown | Signed food inspection report |
| ULP-B | Unlicensed Personnel | Named in medication administration and background study deficiencies |
| ULP-E | Unlicensed Personnel | Named in background study and annual training deficiencies |
| ULP-G | Unlicensed Personnel | Named in medication administration competency deficiency |
| RN-D | Registered Nurse | Named in infection control and medication administration findings |
| LALD-C | Licensed Assisted Living Director | Named in multiple findings including staffing and emergency preparedness |
| BOC-J | Business Office Coordinator | Named in employee record and training documentation deficiencies |
| ULP-F | Unlicensed Personnel | Named in awake staff deficiency |
| ULP-I | Unlicensed Personnel | Named in infection control and catheter care findings |
| ULP-L | Unlicensed Personnel | Named in catheter care training deficiency |
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