Inspection Report
Annual Inspection
Census: 39
Deficiencies: 8
Jan 8, 2025
Visit Reason
The Minnesota Department of Health conducted a full survey to evaluate and assess compliance with state licensing statutes for an assisted living facility with dementia care license.
Findings
The licensee was found in substantial compliance but had several deficiencies including failure to prepare and serve food according to Minnesota Food Code, incomplete emergency preparedness plan, failure to protect resident records privacy, physical environment maintenance issues, incomplete fire safety and evacuation plans and drills, medication administration errors, and unsecured medication storage.
Severity Breakdown
Level 2: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure food was prepared and served according to the Minnesota Food Code, resulting in a level two violation at widespread scope. | Level 2 |
| Failed to have a written emergency preparedness plan with all required content, resulting in a level two violation at widespread scope. | Level 2 |
| Failed to ensure one resident's personal health and medical information was kept private, resulting in a level two violation at widespread scope. | Level 2 |
| Failed to maintain the physical environment in a continuous state of good repair, including unsealed water closets and prevalent cracking on walls and ceilings, resulting in a level two violation at widespread scope. | Level 2 |
| Failed to develop fire safety and evacuation plan with required content and failed to provide required evacuation drills, resulting in a level two violation at widespread scope. | Level 2 |
| Failed to administer medications according to provider orders for one resident, resulting in a level two violation at isolated scope. | Level 2 |
| Failed to ensure prescription medications were securely locked and only accessible to authorized personnel for two residents, resulting in a level two violation at isolated scope. | Level 2 |
| Failed to ensure unlicensed personnel followed appropriate medication administration procedures, resulting in a level two violation at widespread scope. | Level 2 |
Report Facts
Resident census: 39
Correction order compliance period: 7
Correction order compliance period: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Thorson | Supervisor, State Evaluation Team | Signed cover letter for the inspection report |
| Joseph D. Childs | Certified Food Protection Manager | Named in Food and Beverage Establishment Inspection Report |
| Kai Yang | Public Health Sanitarian 1 | Signed Food and Beverage Establishment Inspection Report |
| BOM-A | Business Office Manager | Interviewed regarding emergency preparedness, fire safety, and physical environment deficiencies |
| DON-D | Director of Nursing | Interviewed regarding medication administration and confidentiality |
| ULP-B | Unlicensed Personnel | Observed administering medications and involved in medication administration deficiency |
| ULP-E | Unlicensed Personnel | Observed not following medication administration procedures |
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