Deficiencies (last 1 years)
Deficiencies (over 1 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
28% worse than Minnesota average
Minnesota average: 3.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Follow-Up
Census: 14
Deficiencies: 5
Date: Jul 16, 2025
Visit Reason
Follow-up survey to determine correction of orders from the survey completed on April 24, 2025.
Findings
The follow-up survey verified that the facility is in substantial compliance with previous correction orders.
Deficiencies (5)
Fire sprinkler head coverage was blocked by curtains installed in resident rooms, violating Minnesota Fire Code provisions.
Fire safety and evacuation plan lacked required content including accurate evacuation maps, employee actions, and resident fire protection procedures; training was not provided to staff or residents as required.
Annual training for staff did not include all required topics, specifically review of facility policies and procedures for one licensed practical nurse.
Registered nurse failed to complete a follow-up assessment within 14 days of admission for one resident and failed to complete a comprehensive reassessment within 90 days for another resident.
Delegated medication administration procedures were not followed for one resident; unlicensed personnel applied medication cream without first washing and drying the affected areas as ordered.
Report Facts
Residents present during survey: 14
Days late for 14-day assessment: 4
Days between assessments exceeding limit: 6
Time period for correction: 7
Time period for correction: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Benjamin J. Zwart | Supervisor, State Engineering Services Section | Signed follow-up survey letter. |
| Jodi Johnson | Supervisor, State Evaluation Team | Signed letter regarding correction order reconsideration process. |
| LPN-D | Licensed Practical Nurse | Employee record lacked evidence of required annual training. |
| DM-I | Director of Maintenance | Interviewed regarding fire sprinkler and fire safety plan deficiencies. |
| CNS-B | Clinical Nurse Supervisor | Reviewed resident assessments and medication administration issues. |
| ULP-C | Unlicensed Personnel | Observed not following medication administration procedure for resident R2. |
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