Deficiencies (last 1 years)
Deficiencies (over 1 years)
12 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
208% worse than Minnesota average
Minnesota average: 3.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Follow-Up
Census: 99
Deficiencies: 12
Date: 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.
Deficiencies (12)
Failed to maintain a written emergency preparedness plan with all required content.
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.
Failed to maintain portable fire extinguishers with required annual certification.
Failed to develop fire safety and evacuation plan with required content and provide required training and drills.
Failed to ensure staff had cleared DHS background study prior to direct resident contact for 6 of 9 employees.
Failed to ensure RN conducted direct supervision of staff performing delegated tasks within 30 days for 2 employees.
Failed to ensure employees completed eight hours of annual training including all required topics for one employee.
Failed to finalize a current written service plan within 14 calendar days of start of services for one resident.
Failed to ensure service plans included required content such as schedule and methods of monitoring staff providing services for four residents.
Failed to ensure staff accurately documented medications administered as prescribed for one staff member.
Failed to ensure all medications were securely locked in a substantially constructed compartment for one resident.
Failed to provide a hazard vulnerability or safety risk assessment of the physical environment on and around the property.
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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