Deficiencies per Year
12
9
6
3
0
High
Moderate
Inspection Report
Follow-Up
Census: 99
Deficiencies: 12
Sep 16, 2025
Visit Reason
Follow-up survey to determine correction of orders from the survey completed on July 2, 2025.
Findings
The follow-up survey verified that the facility is in substantial compliance with previous correction orders.
Severity Breakdown
Level 2: 11
Level 3: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to maintain a written emergency preparedness plan with all required content. | Level 2 |
| Failed to comply with Minnesota State Fire Code; multiple fire doors would not close and latch automatically and lacked approved release switches for magnetic locks. | Level 2 |
| Failed to maintain portable fire extinguishers with required annual certification. | Level 2 |
| Failed to develop fire safety and evacuation plan with required content and provide required training and drills. | Level 2 |
| Failed to ensure staff had cleared DHS background study prior to direct resident contact for 6 of 9 employees. | Level 3 |
| Failed to ensure RN conducted direct supervision of staff performing delegated tasks within 30 days for 2 employees. | Level 2 |
| Failed to ensure employees completed eight hours of annual training including all required topics for one employee. | Level 2 |
| Failed to finalize a current written service plan within 14 calendar days of start of services for one resident. | Level 2 |
| Failed to ensure service plans included required content such as schedule and methods of monitoring staff providing services for four residents. | Level 2 |
| Failed to ensure staff accurately documented medications administered as prescribed for one staff member. | Level 2 |
| Failed to ensure all medications were securely locked in a substantially constructed compartment for one resident. | Level 2 |
| Failed to provide a hazard vulnerability or safety risk assessment of the physical environment on and around the property. | Level 2 |
Report Facts
Residents present: 99
Fines assessed: 3500
Background study clearance missing: 6
Employees without direct supervision within 30 days: 2
Residents with incomplete service plans: 1
Residents with incomplete service plan content: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Renee L. Anderson | Supervisor, State Evaluation Team | Author of follow-up survey letter |
| CNS-B | Clinical Nurse Supervisor | Named in findings related to background studies, supervision, service plans, and medication administration |
| LALD-A | Licensed Assisted Living Director | Named in findings related to emergency preparedness, background studies, fire safety, and service plans |
| ULP-C | Unlicensed Personnel | Named in findings related to background studies and medication storage |
| ULP-G | Unlicensed Personnel | Named in medication administration documentation deficiency |
| LPN-F | Licensed Practical Nurse | Named in annual training deficiency |
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