Inspection Report
Routine
Census: 80
Deficiencies: 12
Apr 17, 2025
Visit Reason
The Minnesota Department of Health conducted a full survey to evaluate and assess compliance with state licensing statutes for Duluth Heights Lodge Senior Living.
Findings
The licensee was found in substantial compliance but had several violations including improper use of facility space by a third-party therapy vendor, failure to comply with Minnesota Food Code, missing grievance procedure postings, missing 911 emergency number postings, incomplete employee records and orientation, deficiencies in delegation and competency of unlicensed personnel, arbitration clause issues, incomplete service plans, lack of written instructions for treatments, and improper use and documentation of supportive devices.
Severity Breakdown
Level 1: 1
Level 2: 11
Deficiencies (12)
| Description | Severity |
|---|---|
| Licensee allowed use of facility space by a third-party therapy vendor without proper control and operation responsibility. | Level 2 |
| Failed to ensure food was prepared and served according to Minnesota Food Code. | Level 2 |
| Failed to post required grievance procedure information including contact details for responsible individuals and ombudsman offices. | Level 2 |
| Failed to post 911 emergency number near phones in common areas. | Level 2 |
| Employee records lacked required content including competency evaluations for medication administration and delegated treatments. | Level 2 |
| Resident agreement arbitration clause included a choice of venue provision, violating Minnesota law. | Level 1 |
| Failed to ensure registered nurse ensured training and competency demonstrations were completed for unlicensed personnel before providing care. | Level 2 |
| Staff providing direct services failed to complete orientation to assisted living licensing requirements and regulations before providing services. | Level 2 |
| Orientation to assisted living statutes did not include all required content for multiple employees. | Level 2 |
| Service plan for resident did not include all required content, specifically missing lymphedema compression boots assistance. | Level 2 |
| Registered nurse failed to specify in writing instructions for treatments and therapies for residents and failed to train unlicensed personnel on lymphedema pump and compression wrap application. | Level 2 |
| Failed to provide care and services according to acceptable health care standards for resident using a consumer transfer pole; lacked documentation of installation and staff training. | Level 2 |
Report Facts
Residents present: 80
Correction order time period: 7
Correction order time period: 21
Correction order time period: 2
Sanitizer concentration: 400
Dishwasher temperature: 168
Food temperature: 37
Food temperature: 40
Food temperature: 39
Food temperature: 173
Food temperature: 166
Food temperature: 170
Food temperature: 163
Food temperature: 171
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| ULP-C | Unlicensed Personnel | Named in findings for incomplete competency evaluations and orientation. |
| ULP-F | Unlicensed Personnel | Named in findings for incomplete orientation and lack of competency training. |
| CNS-B | Clinical Nurse Supervisor | Named in findings for incomplete orientation and failure to specify written instructions for treatments. |
| LALD-A | Licensed Assisted Living Director | Named in findings related to facility operations and employee training. |
| ULP-D | Unlicensed Personnel | Named in findings for lack of training on compression wraps. |
| Richard Simmons | Certified Food Protection Manager | Named in food service inspection report for lacking CFPM certificate. |
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