Inspection Report
Routine
Census: 65
Capacity: 70
Deficiencies: 11
Jul 30, 2025
Visit Reason
The Minnesota Department of Health conducted a survey on July 30, 2025, to evaluate and assess compliance with state licensing statutes for Ecumen Duluth The Shores, an assisted living facility with dementia care license.
Findings
The licensee was found in substantial compliance but had violations including unauthorized use of facility space by home health and hospice agencies, failure to ensure proper staffing plans, infection control deficiencies, fire safety code violations, physical environment maintenance issues, incomplete dementia care training for supervisory staff, and medication management errors.
Severity Breakdown
Level 1: 1
Level 2: 10
Deficiencies (11)
| Description | Severity |
|---|---|
| Licensee allowed use of facility space to operate home health care and hospice agencies without demonstrating legal responsibility for control and operation of the facility. | Level 2 |
| Licensee failed to ensure only assisted living services were provided in the facility. | Level 1 |
| Licensee failed to develop and implement a staffing plan to meet residents' needs and respond promptly to emergencies. | Level 2 |
| Food was not prepared and served according to Minnesota Food Code. | Level 2 |
| Licensee failed to maintain an infection control program consistent with CDC guidelines; improper hand hygiene and failure to disinfect shared equipment observed. | Level 2 |
| Licensee failed to comply with Minnesota State Fire Code; controlled egress doors lacked centralized unlocking capability and fire door maintenance issues observed. | Level 2 |
| Physical environment not maintained in good repair; broken walk-in bathtub and cracked sidewalk observed. | Level 2 |
| Supervisory staff failed to complete required dementia care training within 120 working hours of employment. | Level 2 |
| Registered nurse failed to reassess resident for medication management services when resident status changed. | Level 2 |
| Registered nurse failed to develop and maintain current individualized medication management plans for residents including all required content. | Level 2 |
| Medications were not administered per prescriber orders; transcription errors and medication administration errors observed. | Level 2 |
Report Facts
Fine amount: 500
Residents present: 65
Licensed capacity: 70
Dementia care residents: 50
ULPs planned for secured unit day shift: 3
ULPs planned for unsecured unit day shift: 2
Dementia training hours completed by RN-C: 1.75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessie Chenze | Supervisor, State Evaluation Team | Named in letter correspondence regarding inspection and correction orders |
| Wade W. Schadewald | Certified Food Protection Manager | Named in Food & Beverage Inspection Report |
| Deb Kosiak | Public Health Sanitarian 3 | Named in Food & Beverage Inspection Report |
| RN-C | Registered Nurse | Named in relation to incomplete dementia training and medication management plan deficiencies |
| CNS-B | Clinical Nurse Supervisor | Named in relation to staffing plan, infection control, and medication management findings |
| ULP-F | Unlicensed Personnel | Named in relation to infection control deficiencies during resident care |
| ULP-J | Unlicensed Personnel | Named in relation to infection control deficiencies during resident care |
| ULP-H | Unlicensed Personnel | Named in relation to infection control and medication administration observations |
| ULP-K | Unlicensed Personnel | Named in relation to medication administration observations |
| DM-M | Director of Maintenance | Named in relation to fire safety and physical environment findings |
| LALD/RN-A | Licensed Assisted Living Director/Registered Nurse | Named in relation to facility tour and staffing plan |
| ED-N | Executive Director | Named in relation to facility tour and physical environment findings |
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