Inspection Reports for Lakeland Health Services LLC
11840 Foley Boulevard Nw, Coon Rapids, MN 55448, MN, 55448
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Inspection Report
Annual Inspection
Census: 2
Capacity: 10
Deficiencies: 11
Sep 10, 2025
Visit Reason
The Minnesota Department of Health conducted a full survey to evaluate and assess compliance with state licensing statutes for an assisted living facility.
Findings
The facility was found to be in substantial compliance but had multiple violations including food service not fully compliant with Minnesota Food Code, infection control program deficiencies, tuberculosis prevention program gaps, fire safety code violations, incomplete fire safety and evacuation plans, incomplete training and competency evaluations for unlicensed personnel, and medication management documentation issues.
Severity Breakdown
Level 2: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to ensure food was prepared and served according to Minnesota Food Code resulting in a level two violation. | Level 2 |
| Failed to establish and maintain an effective infection control program consistent with CDC guidelines, including hand hygiene and injection administration. | Level 2 |
| Failed to maintain a tuberculosis prevention and control program including two-step TB screening for one employee. | Level 2 |
| Failed to comply with Minnesota State Fire Code including holes in garage wall fire barrier. | Level 2 |
| Failed to provide interconnected smoke alarms in dwelling units. | Level 2 |
| Failed to develop and maintain a complete fire safety and evacuation plan with required content, training, and drills. | Level 2 |
| Failed to obtain building permits and submit plan review applications for construction projects including ramp and door modifications. | Level 2 |
| Failed to ensure required training and competency evaluations were completed for unlicensed personnel including documentation, fall prevention, boundaries, resident needs, and medication administration. | Level 2 |
| Failed to ensure documentation of medication setup included all required content such as dates and person completing setup. | Level 2 |
| Failed to ensure registered nurse developed training and competencies for unlicensed personnel providing medications for unplanned time away. | Level 2 |
| Failed to label time sensitive medications with opened or expiration dates. | Level 2 |
Report Facts
Residents present: 2
Licensed capacity: 10
Fines assessed: 500
Priority 1 orders: 1
Priority 2 orders: 1
Priority 3 orders: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| ULP-C | Unlicensed Personnel | Named in findings related to incomplete training, tuberculosis screening, hand hygiene, medication administration, and competency evaluations |
| CNS-B | Clinical Nurse Supervisor | Observed administering medication and provided statements regarding medication documentation and training |
| LALD-A | Licensed Assisted Living Director | Provided facility tour, verified deficiencies, and discussed training and documentation issues |
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