Inspection Reports for Grace Home And Healthcare Inc
1001 Lynde Drive Northeast., Fridley, MN 55432, MN, 55432
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Inspection Report
Original Licensing
Census: 3
Capacity: 5
Deficiencies: 12
Sep 22, 2023
Visit Reason
The Minnesota Department of Health conducted an initial survey and follow-up to assess compliance with state licensing statutes and determine issuance of an initial license to Grace Home and Healthcare Inc.
Findings
The facility was found not in substantial compliance with Minnesota Statutes Chapter 144G, resulting in denial of the initial assisted living facility license. Multiple deficiencies were identified including failure to notify the department timely of service start, lack of staff access to an on-call registered nurse 24/7, incomplete tuberculosis prevention program, missing contract information, prohibited liability waivers in contracts, incomplete background studies, lack of required employee orientation and annual training, incomplete service plans, and missing signed medication orders.
Severity Breakdown
Level 1: 2
Level 2: 8
Level 3: 2
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to notify Minnesota Department of Health within two days of starting services. | Level 2 |
| Failed to notify commissioner in writing prior to a change in manager or authorized agent within 60 days. | Level 2 |
| Failed to ensure staff had access to an on-call registered nurse 24 hours per day, seven days per week. | Level 3 |
| Failed to establish and maintain a tuberculosis prevention program including required TB screening and training. | Level 2 |
| Failed to include required contract information such as Health Facility Identification number in resident contracts. | Level 1 |
| Contract included language waiving licensee's liability for resident health, safety, or personal property. | Level 1 |
| Failed to ensure background study was conducted for one registered nurse. | Level 3 |
| Failed to ensure employees completed required orientation before providing services. | Level 2 |
| Failed to ensure annual training included all required topics for one employee. | Level 2 |
| Failed to ensure service plan included signature or authentication by resident and facility documenting agreement on services. | Level 2 |
| Service plan lacked required content including fees for services, emergency contacts, and emergency medical service directives. | Level 2 |
| Failed to ensure written or electronically recorded prescriptions were obtained for all medications managed for one resident. | Level 2 |
Report Facts
Active residents at time of survey: 3
Licensed capacity: 5
Deficiency correction timeframes: 21
Deficiency correction timeframes: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria King | Division Director | Signed notice letter from Minnesota Department of Health |
| Kelly Thorson | Supervisor | Contact for notification and transfer of residents |
| RN-B | Registered Nurse | Named in findings related to lack of 24/7 nurse access, TB screening, orientation, and background study |
| O-A | Owner and acting administrator named in multiple findings including notification failures, nurse availability, orientation, training, and contract issues | |
| LALD-D | Licensed Assisted Living Director | Named in relation to background study and staffing |
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