Inspection Reports for
Senior Living LLC
7949 Brunswick Avenue, North Brooklyn Park, MN 55443, MN, 55443
Back to Facility ProfileDeficiencies (last 1 years)
Deficiencies (over 1 years)
35 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
797% worse than Minnesota average
Minnesota average: 3.9 deficiencies/yearDeficiencies per year
36
27
18
9
0
Inspection Report
Follow-Up
Census: 4
Capacity: 4
Deficiencies: 35
Date: Dec 9, 2024
Visit Reason
Follow-up survey conducted to determine correction of orders found on the survey completed August 22, 2024, for an assisted living facility under a conditional license.
Findings
The follow-up survey found the facility to be in substantial compliance with prior correction orders. The original survey identified multiple deficiencies including licensing, staffing, medication management, emergency preparedness, resident records, and physical environment issues. The facility was under a conditional license with restrictions and monitoring requirements.
Deficiencies (35)
Licensed assisted living director was not listed as Director of Record with the Board of Executives for Long Term Services and Supports.
Licensee failed to meet licensure requirements including policies, procedures, and managerial oversight.
Failed to develop and implement a staffing plan including evaluation of staffing levels.
Food was not prepared and served according to Minnesota Food Code.
Staff did not have access to a registered nurse 24/7.
Failed to implement a quality management program appropriate to the size and services of the facility.
Failed to immediately report a missing resident to the Minnesota Adult Abuse Reporting Center.
Employee record lacked job description for one employee.
Failed to maintain tuberculosis prevention and control program including baseline TB screening and training for employees.
Emergency preparedness plan lacked required content including hazard assessment, communication plans, training, and testing.
Resident records lacked current, legible, permanently recorded, dated, and authenticated entries.
Resident records were not secured properly; confidential records and medications were accessible in unsecured garage and common areas.
Resident records lacked required contents including discharge summary and medication documentation.
Physical environment not maintained in good repair including egress windows not meeting size requirements, missing guardrails, leaking pipes, unfinished surfaces, and fire safety deficiencies.
Fire safety and evacuation plan lacked specific employee and resident procedures, training, and drills.
Egress windows in resident bedrooms did not meet minimum size requirements for emergency exit.
Failed to execute written contracts prior to providing housing and assisted living services.
Contracts lacked required content including Health Facility Identification number and information on medical assistance waivers and housing support program.
Contracts lacked required verbatim notice regarding right to designate a representative.
Contracts included waiver of liability for health, safety, or personal property of residents.
Failed to conduct background studies prior to staff providing services.
Failed to ensure registered nurse supervised unlicensed personnel performing delegated nursing tasks within 30 days of start and thereafter as needed.
Failed to provide orientation to assisted living licensing requirements including required topics for some employees.
Failed to provide written or electronic description of dementia care training program to residents and families.
Failed to conduct nursing assessments by registered nurse prior to move-in or contract execution for all residents.
Failed to conduct ongoing nursing reassessments within 14 days and no more than 90 days thereafter for residents.
Service plans lacked signatures documenting agreement and did not include required content such as fees, staff providing services, and monitoring methods.
Failed to complete annual medication reassessments for residents.
Failed to document medication administration and transcribe provider orders accurately.
Failed to document medication setup accurately at time of setup for residents.
Failed to ensure unlicensed personnel demonstrated competency prior to delegation of medication administration.
Failed to develop written procedures for unlicensed personnel administering medications during unplanned time away when licensed nurse unavailable.
Failed to obtain current written or electronic prescriptions for all prescribed medications for residents.
Failed to document disposition of medications upon resident discharge.
Failed to store prescription medications securely to permit only authorized personnel access.
Report Facts
Residents present: 4
Total licensed capacity: 4
Potential fines: 12500
Employee shifts: 3
Medication administration missing initials: 40
Missing medication orders: 3
Missing medication reassessments: 1
Missing medication setup documentation: 4
Missing medication disposition documentation: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LALD-A | Licensed Assisted Living Director | Named in multiple findings related to licensing, staffing, medication management, and compliance |
| CNS-D | Clinical Nurse Supervisor | Named in medication administration training and supervision findings; no longer employed as of August 2024 |
| ULP-B | Unlicensed Personnel | Named in medication administration and supervision findings |
| ULP-C | Unlicensed Personnel | Named in background study and medication administration competency findings |
| ULP-E | Unlicensed Personnel | Named in dementia training and medication administration competency findings |
| Anker Chopra | Assistant Living Director | Person in charge during food and beverage inspection |
| Tim Oyedokun | House Manager | Present during food and beverage inspection |
| Melissa Ramos | Environmental Health Specialist | Conducted food and beverage inspection |
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