Inspection Reports for Sugar Brook Villa
20868 Sugar Hills Road, Cohasset, MN 55721, MN, 55721
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Inspection Report
Routine
Census: 12
Capacity: 12
Deficiencies: 19
May 7, 2025
Visit Reason
The Minnesota Department of Health completed a survey on May 7, 2025, to evaluate and assess compliance with state licensing statutes for Sugar Brook Villa, an assisted living facility.
Findings
The survey identified multiple deficiencies including failure to develop a staffing plan with appropriate metrics, food service violations per Minnesota Food Code, infection control lapses, missing required emergency postings, incomplete emergency preparedness plan, fire safety code violations including exposed foam insulation and lack of interconnected smoke alarms, incomplete fire safety and evacuation plans and training, background study issues for maintenance staff, delegation and documentation deficiencies in medication and treatment administration, medication storage and labeling issues, and failure to maintain resident privacy during medication administration.
Severity Breakdown
Level 1: 1
Level 2: 18
Deficiencies (19)
| Description | Severity |
|---|---|
| Failed to develop a staffing plan that included metrics to identify staffing to meet scheduled and unscheduled needs of residents. | Level 2 |
| Failed to ensure food was prepared and served according to the Minnesota Food Code. | Level 2 |
| Failed to ensure infection control standards were followed by two employees while providing medication and personal care services. | Level 2 |
| Failed to post the required 911 emergency number and other reporting information in common areas. | Level 1 |
| Failed to have a written emergency preparedness plan posted prominently and with all required content, and failed to provide required training and drills. | Level 2 |
| Failed to comply with Minnesota State Fire Code including exposed foam plastic insulation without thermal barrier. | Level 2 |
| Failed to provide interconnected smoke alarms throughout the dwelling unit. | Level 2 |
| Failed to develop fire safety and evacuation plans with required content, make the plan readily available, provide required training and drills. | Level 2 |
| Failed to ensure background study was submitted and clearance received for maintenance employee. | Level 2 |
| Failed to ensure unlicensed personnel were trained and competent on delegated tasks including tilt-n-space wheelchair and warm/cold packs, and failed to provide written instructions in resident records for delegated tasks. | Level 2 |
| Failed to revise resident service plan to include provided services for one resident. | Level 2 |
| Failed to assess residents for ability to self-administer after set up for scheduled medications for two residents. | Level 2 |
| Failed to provide specific written instructions related to administration of medications for three residents. | Level 2 |
| Failed to ensure medications were administered as ordered for one resident. | Level 2 |
| Failed to ensure medications were securely stored and permitted access only to authorized personnel; topical medications were unsecured. | Level 2 |
| Failed to ensure time sensitive medications were maintained with original prescription label including legible expiration or beyond-use date. | Level 2 |
| Failed to prepare in writing specific instructions for delegated treatments for one resident. | Level 2 |
| Failed to provide care and services according to acceptable health care standards by unlicensed personnel during medication administration for one resident. | Level 2 |
| Failed to maintain resident privacy during medication administration for one resident. | Level 2 |
Report Facts
census: 12
total_capacity: 12
fine_amount: 1000
deficiency_count: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessie Chenze | Supervisor, State Evaluation Team | Named in letter of inspection completion |
| LPN-B | Licensed Practical Nurse | Named in multiple findings related to staffing, medication administration, and medication storage |
| CNS-C | Clinical Nurse Supervisor | Named in multiple findings related to staffing, infection control, medication administration, and emergency preparedness |
| ULP-E | Unlicensed Personnel | Named in findings related to infection control, medication administration, and treatment delegation |
| ULP-F | Unlicensed Personnel | Named in findings related to infection control and personal care |
| DM-H | Director of Maintenance | Named in background study deficiency |
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