Inspection Report
Annual Inspection
Census: 46
Deficiencies: 6
Nov 15, 2024
Visit Reason
The Minnesota Department of Health conducted a full survey to evaluate and assess compliance with state licensing statutes for the assisted living facility with dementia care license.
Findings
The survey identified multiple violations including failure to be legally responsible for the entire facility management, food safety violations per Minnesota Food Code, incomplete employee records, fire safety code violations including fire door issues and incomplete fire safety and evacuation plans, and improper oxygen cylinder storage. No immediate fines were assessed.
Severity Breakdown
Level 2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Licensee was not legally responsible for the management, control, and operation of the whole facility including unlicensed independent living apartments. | Level 2 |
| Food was not prepared and served according to the Minnesota Food Code, including cold holding violations. | Level 2 |
| Employee records lacked required content including missing annual performance reviews for two unlicensed personnel. | Level 2 |
| Failure to comply with State Fire Code including fire doors held open improperly and disconnected door closers. | Level 2 |
| Fire safety and evacuation floor plans did not identify location and number of resident sleeping rooms and had inaccurate layouts. | Level 2 |
| Failure to provide care and services according to acceptable health care standards for one resident with oxygen, including improper oxygen cylinder storage. | Level 2 |
Report Facts
Residents present: 46
Food temperature violation: 47
Food temperature violation: 48.4
Number of oxygen cylinders improperly stored: 3
Time period for correction: 21
Time period for correction: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jess Schoenecker | Supervisor, State Evaluation Team | Contact person for informal conference and survey communication |
| Susan Winkelmann | Contact person for survey feedback questionnaire | |
| Michael DeMars | Public Health Sanitarian III | Inspector for Food and Beverage Establishment Inspection |
| CNS-D | Clinical Nurse Supervisor | Provided information on missing employee reviews and oxygen management |
| ESD-F | Environmental Services Director | Provided facility tour and verified fire safety and oxygen storage observations |
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