Inspection Reports for Cascade Creek Memory Care
3530 Fairway Ridge Ln SW, Rochester, MN 55902, United States, MN, 55902
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Inspection Report
Annual Inspection
Census: 45
Deficiencies: 12
Dec 19, 2024
Visit Reason
The Minnesota Department of Health completed a survey to evaluate and assess compliance with state licensing statutes for Cascade Creek Memory Care.
Findings
The licensee was found to be in substantial compliance but had multiple deficiencies including failure to develop individual abuse prevention plans with required content for residents, incomplete employee records, lack of a tuberculosis prevention program, incomplete resident records, fire safety code violations, inadequate fire safety training and drills, failure to provide emergency relocation notices, incomplete resident service plans, improper medication storage temperatures, unlabeled medications, and failure to document medication disposition upon resident discharge.
Severity Breakdown
Level 2: 11
Level 1: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to develop individual abuse prevention plans with required content for three residents (R1, R2, R3). | Level 2 |
| Employee records lacked required content for two employees (ULP-H, ULP-I). | Level 2 |
| Failed to establish and maintain a tuberculosis prevention program including a timely TB risk assessment. | Level 2 |
| Resident record lacked a discharge summary with required content for one discharged resident (R4). | Level 2 |
| Failed to comply with Minnesota State Fire Code regarding egress control locking system on emergency exit doors. | Level 2 |
| Failed to provide required fire safety and evacuation training and drills for staff. | Level 2 |
| Failed to provide written notice with required content for emergency relocation and failed to notify Ombudsman for one resident (R2). | Level 2 |
| Resident service plans lacked required content including monitoring schedules and contingency plans for three residents (R1, R2, R3). | Level 2 |
| Medication refrigerators were not maintained at acceptable temperatures for medications of five residents (R1, R2, R9, R10, R11). | Level 2 |
| Failed to label time sensitive medications with opened dates or proper labels for three residents (R5, R7, R8). | Level 2 |
| Failed to document medication disposition in resident record for one discharged resident (R4). | Level 2 |
| Failed to provide required assisted living with dementia care policies and procedures to residents and their representatives at move-in for three residents (R1, R2, R3). | Level 1 |
Report Facts
Residents present: 45
Medication refrigerator temperature: 44
Medication refrigerator temperature: 34
Medication refrigerator temperature: 41
Medication refrigerator temperature: 30
Medication syringes: 45
Medication syringes: 9
Medication syringes: 5
Medication syringes: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| ULP-H | Unlicensed Personnel | Named in findings related to incomplete employee records and medication administration observation |
| ULP-I | Unlicensed Personnel | Named in findings related to incomplete employee records and medication administration observation |
| Jodi Johnson | Supervisor, State Evaluation Team | Contact person for the survey report |
| ALDIR-A | Assisted Living Director in Residency | Interviewed regarding multiple deficiencies including employee records, TB program, fire safety, emergency relocation, service plans, and policies |
| CNS-B | Clinical Nurse Supervisor | Interviewed regarding medication storage, medication disposition, and abuse prevention plans |
| RN-C | Registered Nurse | Observed medication refrigerator contents and medication administration |
| ESD-K | Environmental Services Director | Accompanied surveyor during fire safety inspection |
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