Inspection Reports for Lincoln Lane Villa
503 E Lincoln St Po Box 106, Hendricks, MN 56136, MN, 56136
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Inspection Report
Annual Inspection
Census: 15
Capacity: 16
Deficiencies: 17
Jul 31, 2025
Visit Reason
The Minnesota Department of Health conducted a full survey at Lincoln Lane Villa on July 31, 2025, to evaluate and assess compliance with state licensing statutes for assisted living facilities.
Findings
The facility was found to be in substantial compliance but had multiple deficiencies including failure to comply with innovation variance related to staffing, inaccurate staff schedules, missing required postings, incomplete resident records, inadequate training and competency evaluations for unlicensed personnel, incomplete service plans, and lack of documentation for medication and treatment administration.
Severity Breakdown
Level 1: 1
Level 2: 15
Deficiencies (17)
| Description | Severity |
|---|---|
| Failure to comply with the terms of an innovation variance related to staffing, resulting in insufficient designated certified nursing assistants on duty as per variance request. | Level 2 |
| Failure to have an accurate daily work schedule posted in a central location accessible to staff, residents, volunteers, and the public. | Level 2 |
| Failure to post the 911 emergency number in common areas and near telephones provided by the assisted living facility. | Level 2 |
| Failure to complete a discharge summary with required content for one discharged resident. | Level 2 |
| Failure to develop the fire safety and evacuation plan with required content and provide required training and drills. | Level 2 |
| Failure to ensure a background study was submitted and received an affiliation with the assisted living license for one dietary aide. | Level 2 |
| Failure to ensure training and competency evaluations were completed as required prior to providing direct care by the lifestyle and wellness coordinator. | Level 2 |
| Failure to ensure employee orientation included all required content for three dietary aides. | Level 2 |
| Failure to ensure annual training included all required topics for the lifestyle and wellness coordinator. | Level 2 |
| Failure to ensure direct care staff received required initial training on mental illness and de-escalation topics within 160 hours of employment start date. | Level 2 |
| Failure to ensure the registered nurse completed a 14-day assessment for one resident receiving services. | Level 2 |
| Failure to ensure the service plan included schedule and methods of monitoring assessments and staff providing services for one resident. | Level 2 |
| Failure to document all required information in the resident's record upon disposition of medications for one discharged resident. | Level 2 |
| Failure to develop and maintain a current individualized treatment and therapy management record for one resident receiving a treatment. | Level 2 |
| Failure to ensure a licensed health professional instructed and specified in writing specific instructions for administering a treatment for one resident. | Level 2 |
| Failure to ensure documentation of a treatment was completed for one resident receiving a treatment. | Level 2 |
| Failure to ensure the current Minnesota Bill of Rights for Assisted Living Residents was provided and a written acknowledgement was received for two residents. | Level 1 |
Report Facts
Residents present: 15
Total licensed capacity: 16
Dates of dietary aide work: 7
Dates of dietary aide work: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LWC-C | Lifestyle and Wellness Coordinator | Named in multiple findings related to lack of training, competency evaluations, and treatment administration |
| CNS-B | Clinical Nurse Supervisor | Named in relation to findings and interviews about assessments, training, and documentation |
| DA-E | Dietary Aide | Named in relation to background study deficiency and orientation |
| DA-H | Dietary Aide | Named in relation to orientation deficiency |
| DA-I | Dietary Aide | Named in relation to orientation deficiency |
| OM-D | Operations Manager | Named in relation to staffing and meal service |
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