Inspection Reports for Community Assisted Living Inc.
13644 Pilot Knob Rd, Apple Valley, MN 55124, MN, 55124
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Inspection Report
Follow-Up
Census: 7
Deficiencies: 17
Sep 10, 2025
Visit Reason
Follow-up survey to determine correction of orders from the survey completed on June 11, 2025.
Findings
The follow-up survey verified that the facility is in substantial compliance with previous correction orders.
Severity Breakdown
Level 2: 15
Level 3: 1
Deficiencies (17)
| Description | Severity |
|---|---|
| Failed to have a written emergency preparedness plan with all required content including communication plan and volunteer use. | Level 2 |
| Failed to ensure entries in resident records were authenticated by name and title of person making the entry for two residents. | Level 2 |
| Failed to ensure resident records included required documentation of all provided services for two residents. | Level 2 |
| Failed to provide compliant emergency escape and rescue openings in resident sleeping rooms 1, 3, and 4. | Level 3 |
| Failed to provide interconnected smoke alarms so that actuation of one alarm causes all alarms to sound. | Level 2 |
| Failed to develop fire safety and evacuation plan with required content including staff actions and resident actions. | Level 2 |
| Failed to provide written notice with required content for emergency relocation and notify Ombudsman for Long-Term Care for one resident. | Level 2 |
| Failed to complete registered nurse change of condition assessment upon resident readmission from hospital and rehab. | Level 2 |
| Failed to revise written service plan to reflect current services provided for two residents. | Level 2 |
| Failed to ensure registered nurse assessed resident's ability to self-administer medications accurately for one resident. | Level 2 |
| Failed to ensure registered nurse documented resident-specific instructions for medication administration delegated to unlicensed personnel for two residents. | Level 2 |
| Failed to document medication setup with all required content including medication name, dose, times, route, and person completing setup for two residents. | Level 2 |
| Failed to ensure prescriber orders were complete and current for two residents including PRN medications and treatments. | Level 2 |
| Failed to ensure prescription drugs, including insulin pens, had pharmacy labels and documented open dates for one resident. | Level 2 |
| Failed to ensure treatments and therapy management plans included all required content for two residents. | Level 2 |
| Failed to ensure treatments and therapies were administered as prescribed or document reasons for not administering for two residents. | Level 2 |
| Failed to provide care and services according to acceptable health care standards for storage of oxygen; unsecured oxygen cylinders observed. | Level 2 |
Report Facts
Residents present: 7
Fine amount: 500
Dates of medication setup documented: 7
Time period for correction: 21
Time period for correction: 7
Time period for correction: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tim Hanna | Supervisor, State Engineering Services Section | Signed follow-up survey letter dated October 14, 2025 |
| Jodi Johnson | Supervisor, State Evaluation Team | Signed survey letter dated August 8, 2025 |
| Barb Ceballos | Owner | Facility representative during food safety inspection June 10, 2025 |
| Peggy Spadafore | Public Health Sanitarian Supervisor | Conducted food safety inspection June 10, 2025 |
| Kassie Markings | MDH Nurse Evaluator | Conducted food safety inspection June 10, 2025 |
| LPN-C | Licensed Practical Nurse | Reviewed records and provided statements regarding medication and treatment deficiencies |
| LALD/CNS-A | Licensed Assisted Living Director/Clinical Nurse Supervisor | Reviewed records and provided statements regarding medication and treatment deficiencies |
| ULP-D | Unlicensed Personnel | Observed administering medications and assisting resident with insulin |
| ULP-F | Unlicensed Personnel | Observed administering medications to resident R2 |
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