Inspection Reports for Hadley House
908 Coney Street West, Perham, MN 56573, MN, 56573
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
High
Inspection Report
Census: 25
Deficiencies: 11
Feb 22, 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.
Findings
The survey identified multiple deficiencies including infection control lapses, incomplete employee records, missing tuberculosis screening, lack of discharge summary for a resident, fire safety violations including missing fire extinguisher inspections and incomplete fire safety plans, incomplete resident assessments and service plans, and medication administration and documentation errors.
Severity Breakdown
Level 2: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to ensure infection control standards were followed for appropriate hand hygiene after glove removal during treatment administration by unlicensed personnel. | Level 2 |
| Failure to ensure employee record included documentation of training and competency for unlicensed personnel providing direct care services. | Level 2 |
| Failure to establish and maintain a comprehensive tuberculosis infection control program including incomplete tuberculosis history and symptom screening for an employee. | Level 2 |
| Failure to ensure resident record included a discharge summary for a discharged resident. | Level 2 |
| Failure to provide documentation of monthly inspections of all fire extinguishers. | Level 2 |
| Failure to develop and maintain a complete fire safety and evacuation plan, provide required employee and resident training, and conduct required evacuation drills. | Level 2 |
| Failure to conduct a comprehensive resident reassessment using a uniform assessment tool within required timeframe after a change in condition. | Level 2 |
| Failure to update the resident's service plan to include administration of sliding scale insulin as ordered. | Level 2 |
| Failure to follow medication administration preparation and documentation process including incomplete documentation of sliding scale insulin units administered and improper insulin pen preparation. | Level 2 |
| Failure to develop and implement a treatment or therapy management plan including specific resident instructions, notification procedures, and documentation requirements for compression stocking treatment. | Level 2 |
| Failure to document administration of treatment or therapy including compression stockings in the resident record. | Level 2 |
Report Facts
Residents present: 25
Correction order timeframes: 7
Correction order timeframes: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| ULP-F | Unlicensed Personnel | Named in infection control and medication administration deficiencies |
| ULP-G | Unlicensed Personnel | Named in employee record, tuberculosis screening, treatment administration, and medication administration deficiencies |
| RN-D | Registered Nurse | Named in infection control, employee record, discharge summary, resident assessment, and medication administration deficiencies |
| CNS-B | Clinical Nurse Supervisor | Named in discharge summary, resident assessment, treatment and therapy management deficiencies |
| EM-C | Employee Manager | Named in discharge summary and resident assessment deficiencies |
| Jessie Chenze | Supervisor, State Evaluation Team | Contact for correction order reconsideration |
| Matthew Johnson | Operator | Named in food and beverage establishment inspection |
| Bailey Bannon | Environmental Health Specialist | Signed food and beverage establishment inspection report |
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