Deficiencies per Year
4
3
2
1
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Routine
Census: 163
Capacity: 76
Deficiencies: 3
Oct 29, 2025
Visit Reason
The Minnesota Department of Health conducted a routine survey on October 29, 2025, to evaluate and assess compliance with state licensing statutes following a change of ownership at the facility.
Findings
The licensee was found to be in substantial compliance but had several deficiencies including failure to maintain an effective infection control program related to glove use, failure to obtain signed service plans for new services for one resident, and failure to securely store medications for multiple residents. No immediate fines were assessed.
Severity Breakdown
Level 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to establish and maintain an effective infection control program related to gloving for two employees, resulting in improper hand hygiene practices. | Level 2 |
| Failed to include a signature or other authentication by the facility and resident documenting agreement on treatment services for one resident (R2). | Level 2 |
| Failed to store all medications in a securely locked location for five residents (R4, R5, R6, R7, R8), with unsecured OTC and supplement medications accessible in resident apartments. | Level 2 |
Report Facts
Residents present: 163
Total licensed capacity: 76
Deficiency count: 3
Time period for correction: 7
Time period for correction: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| ULP-J | Unlicensed Personnel | Named in infection control deficiency related to improper glove use and hand hygiene |
| ULP-K | Unlicensed Personnel | Named in infection control deficiency related to improper glove use and hand hygiene |
| Casey DeVries | Supervisor, State Evaluation Team | Signed the cover letter for the inspection report |
| CNS-C | Clinical Nurse Supervisor | Interviewed regarding infection control training and medication management |
| RCD-E | Regional Clinical Director | Interviewed regarding infection control training, service plans, and medication management |
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