Deficiencies (last 1 years)
Deficiencies (over 1 years)
24 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
515% worse than Minnesota average
Minnesota average: 3.9 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Follow-Up
Census: 66
Deficiencies: 24
Date: Sep 25, 2024
Visit Reason
Follow-up survey to determine correction of orders from the initial survey completed on May 24, 2024.
Findings
The follow-up survey found the facility in substantial compliance but identified uncorrected state correction orders related to training and evaluation of unlicensed personnel, documentation of medication administration, disposition of medications, and other regulatory requirements. Several deficiencies were cited with severity levels and pattern scope.
Deficiencies (24)
Failed to ensure training and competency was completed for five unlicensed personnel to include all required content.
Failed to ensure training and competency was completed for five unlicensed personnel to include all required content related to additional training requirements.
Failed to ensure staffing plan was evaluated twice a year to ensure appropriate staffing levels.
Failed to ensure food was prepared and served according to the Minnesota Food Code.
Failed to implement and maintain a quality management program appropriate to the size of the facility and relevant to the type of services provided.
Failed to develop individual abuse prevention plans for five residents including required content and interventions.
Failed to establish and maintain a tuberculosis prevention program including documentation of TB history and symptom screening for one employee.
Failed to ensure entries in resident records were authenticated by name and title of person making the entry for six residents.
Failed to ensure resident records included documentation that all services were provided as scheduled for five residents.
Failed to comply with State Fire Code requirements for interconnected smoke alarms in resident apartments.
Failed to maintain physical environment in continuous state of good repair including fire doors, extension cords, and exit gates.
Failed to comply with existing construction requirements for assisted living with dementia care including hazard vulnerability assessment and mitigation.
Failed to designate a qualified person to oversee staff training in care of individuals with dementia.
Failed to conduct individualized activity evaluations addressing all required provisions and develop individualized activity plans for two residents.
Failed to provide care and assisted living services according to acceptable health care standards for residents with hospital-style and consumer purchased side rails.
Failed to conduct medication management assessments including review of all medications for four residents prior to providing medication management services.
Failed to develop individualized medication management plans with all required content for four residents.
Failed to document medication administration including signatures, medication details, and reasons for missed medications for residents.
Failed to ensure current written or electronically recorded prescriptions for all medications managed for residents including frequency and discontinued orders.
Failed to ensure all medications were securely locked in substantially constructed compartments with access limited to authorized personnel.
Failed to document disposition of medications including prescription numbers and recipient for one discharged resident.
Failed to develop and maintain individualized treatment or therapy management plans with all required content for three residents.
Failed to maintain up-to-date written or electronically recorded treatment orders for two residents.
Failed to ensure supervising staff had required experience and knowledge in care of individuals with dementia.
Report Facts
Residents present: 66
Residents receiving dementia care: 57
Potential fines: 3000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ULP-C | Unlicensed Personnel | Named in multiple findings related to training, competency, documentation, and medication administration |
| ULP-E | Unlicensed Personnel | Named in multiple findings related to training, competency, documentation, and medication administration |
| RN/C-D | Registered Nurse/Consultant | Named in findings related to medication administration, side rail assessments, and documentation |
| RN-B | Registered Nurse | Named in findings related to medication administration, documentation, and assessments |
| LALD-A | Licensed Assisted Living Director | Named in findings related to staffing, training, and compliance |
| MD-H | Maintenance Director | Named in findings related to fire safety and physical environment |
| MCM-I | Memory Care Manager | Named in findings related to activity evaluation and staff training |
Loading inspection reports...
