Inspection Reports for
Ecumen North Branch
5379 383rd Street, North Branch, MN, 55056
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
4.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
21% worse than Minnesota average
Minnesota average: 3.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 3
Date: Jul 24, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and included complaint surveys to assess compliance with regulatory standards.
Findings
The facility failed to ensure previous survey results were available to residents, stored food preparation items in an unsanitary manner, and did not prevent damp laundry from being left overnight in washing machines, posing potential risks to residents.
Deficiencies (3)
F 0577: The facility failed to ensure the previous year's survey results were available to residents and visitors. The last recertification and two complaint surveys were missing from the survey results binder.
F 0812: The facility failed to store food preparation items in a sanitary manner. Five of nine steam table pans were stored with visible moisture, increasing risk for bacterial growth.
F 0880: The facility failed to ensure damp laundry was not left overnight in washing machines. Laundry staff started loads at shift end, leaving damp items overnight, increasing infection risk for 44 residents.
Report Facts
Residents affected: 44
Steam table pans observed: 9
Steam table pans stored wet: 5
Inspection Report
Routine
Deficiencies: 7
Date: Aug 9, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, infection control, care planning, and food safety at the nursing home.
Findings
The facility was found deficient in multiple areas including failure to comprehensively assess residents for self-administration of medications, incomplete baseline and comprehensive care plans, failure to follow provider orders for skin assessments and medication administration, inadequate documentation and review of PRN opioid medication, improper food storage and labeling, and failure to adhere to infection prevention and control protocols during a COVID-19 outbreak.
Deficiencies (7)
F 0554: The facility failed to ensure residents were comprehensively assessed for self-administration of medications for 1 of 5 residents reviewed.
F 0655: The facility failed to develop and implement a baseline care plan within 48 hours of admission for 1 of 1 resident reviewed.
F 0657: The facility failed to review and revise the care plan with current interventions for pressure ulcer care for 1 of 2 residents reviewed.
F 0684: The facility failed to follow provider orders for weekly skin assessments and PRN medication administration for 1 of 2 residents reviewed.
F 0757: The facility failed to have appropriate documentation and physician review for an as needed opioid medication ordered for 1 of 5 residents reviewed.
F 0812: The facility failed to ensure food was stored in accordance with regulations, including labeling and dating resident food and removing expired food from unit refrigerators.
F 0880: The facility failed to adhere to CDC recommendations for testing, cohorting, and transmission-based precautions during a COVID-19 outbreak affecting multiple residents and staff.
Report Facts
Weight gain: 4.4
Weight gain: 3
Deficiencies cited: 7
COVID-19 positive cases: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-A | Licensed Practical Nurse | Named in medication administration and infection control findings |
| LPN-B | Licensed Practical Nurse | Named in medication administration and care plan findings |
| RN-A | Registered Nurse | Named in care plan and baseline care plan findings |
| ADON | Assistant Director of Nursing | Named in multiple interviews regarding medication, care plans, and infection control |
| DON | Director of Nursing | Named in infection control and care plan findings |
| RN-B | Registered Nurse | Named in medication review findings |
| PC | Pharmacy Consultant | Named in opioid medication review findings |
| CD | Culinary Director | Named in food storage and safety findings |
| NA-A | Nursing Assistant | Named in infection control findings |
| HK-A | Housekeeper | Named in infection control findings |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jun 17, 2024
Visit Reason
The inspection was conducted to assess compliance with care planning requirements, specifically evaluating the development and maintenance of comprehensive care plans to ensure appropriate fall interventions for residents.
Findings
The facility failed to ensure a comprehensive care plan was developed and maintained for one resident at high risk for falls. The resident's care plan and nursing assistant care sheet lacked fall risk information and fall interventions, increasing the potential for resident injury.
Deficiencies (1)
F 0636: The facility failed to develop and maintain a comprehensive care plan including fall risk and fall interventions for one resident at high risk for falls. The resident's care plan dated 6/10/24 and nursing assistant care sheet lacked fall interventions despite documented high fall risk.
Report Facts
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN-B | Registered Nurse | Stated care plan would be updated with new intervention after a resident fall |
| ADON | Assistant Director of Nursing | Confirmed resident did not have fall risk or fall interventions in care plan or nursing assistant care sheet |
| NP-A | Nurse Practitioner | Stated all residents should have documented fall interventions |
| LPN-A | Licensed Practical Nurse | Stated she would look in care plan and nursing assistant care sheet for fall interventions |
| RN-A | Registered Nurse | Confirmed resident's care plan did not include fall risk or fall interventions |
| LPN-B | Licensed Practical Nurse | Stated resident was not a fall risk because no care plan addressing falls existed |
Inspection Report
Deficiencies: 3
Date: Sep 27, 2023
Visit Reason
The inspection was conducted to assess compliance with respiratory care, infection prevention and control, antibiotic use monitoring, and related regulatory requirements at the nursing home.
Findings
The facility failed to maintain oxygen equipment properly, ensure adequate sanitization of shared glucometers, enforce hand hygiene during medication passes and wound care, display appropriate contact precaution signage, and implement antibiotic use protocols to avoid unnecessary antibiotic use for a resident on hospice care.
Deficiencies (3)
F 0695: The facility failed to maintain oxygen equipment according to policy by not routinely changing a nasal cannula for one resident, risking infection.
F 0880: The facility failed to ensure shared glucometers were sanitized after use, staff performed inadequate hand hygiene during medication passes and wound care, and failed to display proper contact precaution signage for a resident.
F 0881: The facility failed to utilize antibiotic use protocols to avoid unnecessary or inappropriate antibiotic use for one resident on hospice care.
Report Facts
Residents reviewed for respiratory care: 2
Residents reviewed for glucometer use: 8
Residents observed during medication pass: 6
Residents observed for wound care: 1
Residents affected by deficiencies: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN)-A | Confirmed oxygen tubing change dates and described oxygen care. | |
| Director of Nursing (DON) | Provided expectations on oxygen tubing changes, infection prevention, and contact precaution signage. | |
| Licensed Practical Nurse (LPN)-C | Observed assisting with blood sugar checks and glucometer sanitization. | |
| Registered Nurse (RN)-A | Observed medication pass and wound care with hand hygiene failures; provided interviews on antibiotic use and precautions. | |
| Nursing Assistant (NA-A) | Observed putting on PPE for resident on contact precautions. | |
| Hospice Licensed Practical Nurse (HLPN) | Provided interview on hospice standards and antibiotic use. | |
| Licensed Practical Nurse (LPN)-B | Reviewed orders and provided interview on resident antibiotic use and bowel history. |
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