Inspection Reports for Anne’s Place LLC
1137 Brainerd Avenue, Duluth, MN 55811, MN, 55811
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Inspection Report
Follow-Up
Census: 3
Capacity: 3
Deficiencies: 12
Dec 21, 2023
Visit Reason
Follow-up survey conducted on December 21, 2023, to determine if orders from the October 3, 2023, survey were corrected.
Findings
The follow-up survey verified that the facility is in substantial compliance with previous correction orders. The original survey on October 3, 2023, identified multiple deficiencies including staffing schedule posting, food service violations, emergency preparedness plan deficiencies, fire safety and evacuation plan issues, training and supervision of unlicensed personnel, medication administration errors, medication storage temperature issues, and medication disposition documentation.
Severity Breakdown
Level 1: 1
Level 2: 10
Level 3: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to ensure the staffing schedule was posted as required, affecting all residents, staff, and visitors. | Level 2 |
| Failed to ensure food was prepared and served according to the Minnesota Food Code. | Level 2 |
| Failed to post a menu a week in advance that was made available to all residents. | Level 1 |
| Failed to develop and post a written emergency preparedness plan with all required content. | Level 2 |
| Failed to maintain the facility's fire safety and evacuation plan with required elements. | Level 2 |
| Failed to provide resident bedrooms #1, #2 and #3 with minimum existing emergency escape and rescue window sizes meeting the minimum state standard. | Level 3 |
| Failed to ensure training and competency was completed for one unlicensed personnel to include all required content. | Level 2 |
| Failed to ensure training and competency was completed for one unlicensed personnel to include additional required content. | Level 2 |
| Failed to ensure direct supervision of staff performing delegated tasks was provided within 30 calendar days after the individual began working. | Level 2 |
| Failed to ensure the steps of the medication administration process were followed for one employee observed administering medications. | Level 2 |
| Failed to ensure the medication refrigerator maintained an acceptable temperature. | Level 2 |
| Failed to document in the resident's record the disposition of medications upon discharge. | Level 2 |
Report Facts
Census: 3
Total Capacity: 3
Fine Amount: 3000
Temperature: 42
Window Opening Measurements: 282
Window Opening Measurements: 616
Window Opening Measurements: 295
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| ULP-D | Unlicensed Personnel | Named in findings related to incomplete training, lack of supervision, and medication administration errors |
| CNS-C | Clinical Nurse Supervisor | Interviewed and provided information on training, supervision, and compliance |
| LALD-B | Licensed Assisted Living Director | Interviewed and provided information on fire safety, emergency preparedness, and compliance |
| Jessie Chenze | Supervisor, State Evaluation Team | Signed follow-up survey letter |
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