Deficiencies (last 1 years)
Deficiencies (over 1 years)
36 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
823% worse than Minnesota average
Minnesota average: 3.9 deficiencies/yearDeficiencies per year
36
27
18
9
0
Inspection Report
Follow-Up
Census: 28
Capacity: 33
Deficiencies: 36
Date: Dec 13, 2023
Visit Reason
Follow-up survey conducted to determine correction of orders found on the survey completed September 1, 2023.
Findings
The facility was found in substantial compliance overall but had not corrected all state correction orders. Several violations were identified including failure to immediately report maltreatment, lack of individual abuse prevention plan for an unlicensed personnel residing on site, incomplete emergency preparedness plan, non-interconnected smoke alarms, incomplete fire safety and evacuation plans and training, missing menus and grievance procedure postings, incomplete employee records, incomplete quality management activities, failure to file timely maltreatment reports, incomplete resident assessments, incomplete medication management documentation, and unsafe bed rails.
Deficiencies (36)
Failure to immediately report maltreatment of a resident with an unwitnessed fall resulting in injury.
Failure to develop an individual abuse prevention plan for an unlicensed personnel residing on site.
Failure to develop and post a complete written emergency preparedness plan.
Failure to provide interconnected smoke alarms throughout the facility.
Failure to develop complete fire safety and evacuation plans and provide required training and drills.
Failure to post menus at least one week in advance and make them available to residents.
Failure to post grievance procedure and contact information for responsible persons and ombudsman.
Failure to display the original current license at the main entrance of the facility.
Failure to maintain a staffing plan and post staffing schedules.
Failure to ensure food was prepared and served according to the Minnesota Food Code.
Failure to provide menus prepared at least one week in advance and made available to residents.
Failure to maintain a current grievance procedure with required contact information.
Failure to maintain current records of employees including job descriptions for some staff.
Failure to develop and post a complete emergency preparedness plan with all required elements.
Failure to provide interconnected smoke alarms in sleeping rooms and immediate vicinity.
Failure to provide readily accessible and visible portable fire extinguishers within 75 feet travel distance.
Failure to maintain physical environment in good repair including fire alarm inspections, exit lights, water leaks, and clear electrical panels.
Failure to develop complete fire safety and evacuation plans including training and drills.
Failure to ensure magnetic locks on exit doors are fail safe to release on fire alarm or power loss.
Failure to execute written assisted living contracts with all required content for residents.
Failure to provide written notice of emergency relocation with required content and notify ombudsman if resident does not return within 4 days.
Failure to ensure background studies were affiliated with the assisted living license for several employees.
Failure to ensure required training and competency evaluations for unlicensed personnel including fall prevention and nutrition.
Failure to ensure orientation to assisted living statutes including required content for employees.
Failure to ensure annual training including dementia care training for employees.
Failure to ensure individualized treatment and therapy management plan for residents receiving treatments.
Failure to monitor and document medication refrigerator temperatures and secure medications properly.
Failure to maintain prescription medications in original containers with legible labels and expiration dates and failure to remove expired medications.
Failure to document effectiveness of PRN medications and failure to administer medications as ordered.
Failure to document medication setup with required content including medication name, dose, route, and time.
Failure to ensure delegation of medication administration to unlicensed personnel included RN training and competency demonstration.
Failure to ensure medication administration documentation included all required elements.
Failure to ensure employees received required dementia care training within required timeframes.
Failure to ensure designated person overseeing dementia care training had documented competency or knowledge test.
Failure to provide care and services according to acceptable health care standards for residents using bed rails including lack of assessment, unsafe installation, and lack of recall checks.
Failure to post signage at facility entrances disclosing electronic monitoring devices.
Report Facts
Residents present: 28
Licensed capacity: 33
Fines assessed: 1500
Medication refrigerator temperature: 36
Medication refrigerator temperature: 36
Medication refrigerator temperature: 36
Medication refrigerator temperature: 36
Medication refrigerator temperature: 36
Medication refrigerator temperature: 36
Medication refrigerator temperature: 36
Medication refrigerator temperature: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LALD-A | Licensed Assisted Living Director | Named in multiple findings including failure to file MAARC reports, incomplete policies, and training deficiencies |
| CNS-B | Clinical Nurse Supervisor | Named in medication and training deficiencies |
| LPN-C | Licensed Practical Nurse | Named in medication and training deficiencies |
| ULP-E | Unlicensed Personnel | Named in medication administration and training deficiencies |
| ULP-G | Unlicensed Personnel | Named in medication administration and training deficiencies |
| ULP-H | Unlicensed Personnel | Named in medication administration and training deficiencies |
| C-I | Cook | Named in training deficiency |
| M-H | Maintenance | Named in physical environment and fire safety findings |
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