Deficiencies per Year
12
9
6
3
0
Severe
High
Inspection Report
Annual Inspection
Census: 72
Deficiencies: 10
Jan 25, 2023
Visit Reason
The Minnesota Department of Health conducted an evaluation to assess compliance with state licensing statutes for assisted living with dementia care.
Findings
The inspection identified multiple deficiencies including failure to maintain a quality management program, missing smoke alarms, inadequate physical environment maintenance, incomplete fire safety and evacuation plans and training, contract language waiving facility liability, incomplete employee orientation and dementia care training, lack of hazard vulnerability assessment, missing required policies and procedures for dementia care, and failure to develop individualized activity plans for residents.
Severity Breakdown
Level 2: 9
Level 1: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to implement and maintain a quality management program appropriate to the size and services of the facility. | Level 2 |
| Failed to provide a working smoke alarm inside the sleeping room of resident apartment unit 208. | Level 2 |
| Failed to maintain the physical environment in a continuous state of good repair, including fire alarm panel trouble, unclean resident units, missing door self-closing hardware, dirty HVAC filters, electrical hazards, and chemical safety issues. | Level 2 |
| Failed to provide complete fire safety and evacuation plans, adequate employee training and drills, and resident evacuation training. | Level 2 |
| Assisted living contract included language waiving facility liability for resident health, safety, or personal property. | Level 1 |
| Failed to ensure one employee received orientation to assisted living licensing requirements before providing services. | Level 2 |
| Failed to ensure employees received required dementia care training hours. | Level 2 |
| Failed to develop a hazard vulnerability or safety risk assessment plan to protect memory care residents from harm. | Level 2 |
| Failed to provide required dementia care policies and procedures to residents at move-in. | Level 2 |
| Failed to have individualized activity plans based on evaluations for residents in the dementia care unit. | Level 2 |
Report Facts
Residents present: 72
Residents receiving dementia care: 38
Time period for correction: 21
Time period for correction: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jonathan Hill | Supervisor, Health Regulation Division, State Evaluation Team | Signed the licensing orders letter |
| Johnnie Johnson | Chef Manager | Signed the food service inspection report |
| Melissa Ramos | Environmental Health Specialist | Conducted the food service inspection |
| ULP-C | Unlicensed Personnel | Failed to receive orientation to assisted living licensing requirements before providing services |
| RN-B | Registered Nurse | Failed to complete required dementia care training within 80 working hours of employment |
| LALD-A | Licensed Assisted Living Director | Acknowledged multiple findings including fire safety deficiencies and orientation/training issues |
| DM-E | Director of Maintenance | Acknowledged physical environment and fire safety deficiencies |
| LED-F | Life Enrichment Director | Confirmed lack of individualized activity plans for residents |
| RD-G | Regional Director | Confirmed contract language waiving facility liability and failure to provide required policies to residents |
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