Inspection Reports for Alnas Lodge LLC
2521 Edinbrook Terrace, North Brooklyn Park, MN 55443, MN, 55443
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Inspection Report
Original Licensing
Census: 1
Deficiencies: 18
Dec 19, 2024
Visit Reason
The Minnesota Department of Health conducted an initial survey to assess compliance with state licensing statutes and determine issuance of an initial license to Alnas Lodge LLC.
Findings
The survey identified multiple deficiencies including failure to provide accurate information, inadequate staffing, medication administration issues, infection control lapses, incomplete emergency preparedness, and physical environment concerns. An immediate correction order was issued related to unlicensed personnel administering medications without demonstrated competency.
Severity Breakdown
Level 1: 0
Level 2: 15
Level 3: 2
Deficiencies (18)
| Description | Severity |
|---|---|
| Failed to provide accurate and truthful information during the survey. | Level 2 |
| Failed to ensure sufficient staffing at all times to meet resident needs, including availability of two staff for resident requiring two-person assistance. | Level 3 |
| Failed to ensure food was prepared and served according to Minnesota Food Code. | Level 2 |
| Failed to establish and maintain an effective infection control program including proper hand hygiene. | Level 2 |
| Failed to comply with requirements for reporting suspected maltreatment of a vulnerable adult. | Level 2 |
| Failed to post 911 emergency number near telephones provided by the facility. | Level 2 |
| Failed to maintain complete employee records including job descriptions for staff. | Level 2 |
| Failed to establish and maintain a tuberculosis prevention program including baseline testing and screening within 90 days of hire. | Level 2 |
| Failed to maintain a written emergency preparedness plan with all required content. | Level 2 |
| Failed to provide carbon monoxide detectors in required locations. | Level 2 |
| Failed to maintain physical environment in good repair including water damage and missing light fixture cover. | Level 2 |
| Failed to develop fire safety and evacuation plan with required content and provide required training. | Level 2 |
| Failed to provide required training and competency evaluations for unlicensed personnel prior to providing services. | Level 2 |
| Failed to develop and maintain individualized medication management record with all required content for resident. | Level 2 |
| Failed to ensure registered nurse trained unlicensed personnel in medication administration and verified competency prior to delegation. | Level 3 |
| Failed to specify in writing and document instructions for administration of treatments in resident record. | Level 2 |
| Limited resident rights by requiring residents to follow house rules including alcohol restrictions. | Level 2 |
| Failed to provide care and services according to acceptable health care standards including lack of bedrail assessment and incomplete medication administration processes. | Level 2 |
Report Facts
Resident count: 1
Medication administration times: 3
Staff shifts: 3
Staff shifts: 2
Medication count: 4
Temperature: 40
Dish machine temperature: 160
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| ULP-B | Unlicensed Personnel | Named in medication administration and competency findings |
| ULP-G | Unlicensed Personnel | Named in medication administration and competency findings |
| CNS/LALD-D | Clinical Nurse Supervisor/Licensed Assisted Living Director | Named in multiple findings including staffing, medication administration, infection control, and emergency preparedness |
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