Inspection Reports for Agate Bay Assisted Living LLC
414 1st Avenue, Two Harbors, MN 55616, MN, 55616
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20
15
10
5
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Follow-Up
Census: 7
Capacity: 10
Deficiencies: 18
Aug 28, 2025
Visit Reason
Follow-up survey to determine correction of orders found on the survey completed on June 5, 2025.
Findings
The facility had not corrected all state correction orders from the June 5, 2025 survey. Deficiencies included food service violations, lack of daily social and recreational activities, missing emergency preparedness elements, incomplete staff records, fire safety code violations including non-compliant emergency escape openings, smoke alarm issues, physical environment disrepair, incomplete resident assessments, medication administration errors, and missing signage for electronic monitoring.
Severity Breakdown
Level 1: 3
Level 2: 12
Level 3: 3
Deficiencies (18)
| Description | Severity |
|---|---|
| Food was not prepared and served according to Minnesota Food Code; cook lacked knowledge of cooking temperatures. | Level 2 |
| Failed to have daily programs of social and recreational activities based on individual and group interests, physical, mental, and psychosocial needs. | Level 2 |
| Failed to post required 911 emergency number in common areas and near telephones. | Level 2 |
| Failed to maintain current employee records including annual performance reviews and tuberculosis screening. | Level 2 |
| Failed to develop and post a comprehensive emergency preparedness plan with all required content. | Level 2 |
| Failed to ensure resident records contained all required documentation including delegated task instructions and medication administration documentation. | Level 2 |
| Failed to provide compliant emergency escape and rescue openings in resident sleeping rooms; windows did not meet minimum clear opening size. | Level 3 |
| Smoke alarms were not interconnected and some were non-functional or outdated beyond 10 years. | Level 2 |
| Exit signs not lit at all times; exterior exit stairways missing guardrails and handrails; electrical hazards including missing junction box covers and improper extension cord use. | Level 3 |
| Failed to maintain physical environment in good repair including plumbing leaks, deteriorated roof, ceiling damage, and water heater leaks. | Level 1 |
| Failed to develop fire safety and evacuation plan with required content including posting on all floors, resident-specific evacuation procedures, training, and drills. | Level 2 |
| Failed to ensure current employee had a cleared background study. | Level 3 |
| Failed to ensure unlicensed personnel were trained and demonstrated competency for delegated tasks including use of motorized stairlift; no written instructions in resident record. | Level 2 |
| Failed to conduct nursing assessments including motion and pressure alarm use for residents. | Level 2 |
| Failed to document medication administration properly including priming insulin pens as per manufacturer instructions and documenting reasons for missed medications. | Level 2 |
| Failed to maintain medications with legible prescription labels including opened and expiration dates for time-sensitive medications. | Level 2 |
| Failed to provide care and services according to accepted health care standards including proper use of motorized stairlift and medication administration steps. | Level 2 |
| Failed to post required signage at facility entrance disclosing electronic monitoring devices. | Level 1 |
Report Facts
Residents present: 7
Total licensed capacity: 10
Fine amount: 6500
Priority 2 orders: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessie Chenze | Supervisor, State Evaluation Team | Named in enforcement letter and contact for reconsideration |
| LALD/CNS-A | Licensed Assisted Living Director/Clinical Nurse Supervisor | Named in multiple findings related to staff training, assessments, medication administration, and stairlift use |
| HM-B | Housing Manager | Named in multiple findings related to facility tour, staff records, fire safety, and physical environment |
| ULP-D | Unlicensed Personnel | Named in findings related to background study and delegated task competency |
| ULP-E | Unlicensed Personnel | Named in findings related to medication administration and delegated task competency |
| ULP-C | Unlicensed Personnel | Named in findings related to medication administration |
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