Inspection Report
Follow-Up
Census: 50
Deficiencies: 27
Mar 15, 2023
Visit Reason
Follow-up evaluation to determine if orders from the January 13, 2023 evaluation were corrected.
Findings
The facility was found to be in substantial compliance during the follow-up evaluation. The original inspection identified multiple deficiencies including staffing, infection control, medication management, emergency preparedness, resident record keeping, and fire safety.
Severity Breakdown
Level 1: 1
Level 2: 26
Level 3: 3
Deficiencies (27)
| Description | Severity |
|---|---|
| Failed to show managerial officials understood applicable statutes and rules and failed to develop and implement required policies and procedures. | Level 2 |
| Failed to develop and implement a staffing plan including posting daily work schedules and conducting evaluations twice a year. | Level 2 |
| Failed to ensure food was prepared according to Minnesota Food Code. | Level 2 |
| Failed to maintain an effective infection control program including improper glove use and medication administration. | Level 2 |
| Failed to maintain current employee records including competency evaluations and background studies. | Level 2 |
| Failed to have a written emergency disaster plan with required content and failed to post emergency plan prominently. | Level 2 |
| Failed to protect resident personal health and medical information from unauthorized disclosure. | Level 2 |
| Failed to include discharge summary in resident record for discharged resident. | Level 2 |
| Failed to provide smoke alarms immediately outside sleeping areas in two-bedroom apartments and failed to interconnect smoke alarms. | Level 2 |
| Failed to maintain physical environment in good repair including fire sealant penetrations and sprinkler head maintenance. | Level 2 |
| Failed to develop and maintain fire safety and evacuation plans and provide required training to residents and employees. | Level 2 |
| Failed to provide written notice with required content for emergency relocation and failed to notify Office of Ombudsman for Long-Term Care. | Level 2 |
| Failed to provide notice to Office of Ombudsman for Long-Term Care or Mental Health and Developmental Disabilities of curtailment and transfers prior to notifying residents. | Level 2 |
| Failed to submit and receive background studies for employees under current license. | Level 3 |
| Failed to provide delegated training by registered nurse to unlicensed personnel for use of external female catheter. | Level 2 |
| Failed to ensure staff completed orientation to assisted living licensing requirements before providing services. | Level 2 |
| Failed to ensure staff completed required annual training including review of assisted living bill of rights. | Level 2 |
| Failed to conduct resident reassessment and monitoring within required timeframes. | Level 2 |
| Failed to revise service plan based on change of service and failed to obtain resident or representative signature on service plan. | Level 2 |
| Failed to ensure registered nurse trained unlicensed personnel in medication administration and verified competency. | Level 3 |
| Failed to document medication administration accurately including insulin pen priming and medication errors. | Level 2 |
| Failed to securely store medications and permit only authorized personnel access; powders and creams stored improperly. | Level 2 |
| Failed to maintain medications with original prescription labels and failed to label time sensitive medications with date opened. | Level 2 |
| Failed to document disposition of medications for discharged residents including medication name, strength, prescription number, and quantity. | Level 2 |
| Failed to ensure awake staff physically present 24/7 in secured dementia care units to respond to resident requests. | Level 3 |
| Failed to provide policies and procedures for assisted living with dementia care to residents or representatives at move-in. | Level 2 |
| Failed to provide written or electronic description of dementia care training program to residents, families, or others upon request. | Level 1 |
Report Facts
Residents present: 50
Residents receiving dementia care: 47
Fines assessed: 9500
Deficiency counts: 30
Temperature: 166.6
Temperature: 169
Temperature: 166
Temperature: 40
Temperature: 39
Temperature: 171
Days between nursing assessments: 166
Days between nursing assessments: 110
Days between nursing assessments: 134
Days between nursing assessments: 139
Days between nursing assessments: 188
Days medication open: 43
Days medication open: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Casey DeVries | Supervisor, Health Regulation Division, State Evaluation Team | Signed follow-up evaluation letter |
| Anthony Guerrieri | Head Cook | Certified Food Protection Manager named in food inspection report |
| Jeff Johanson | Unknown | Signed food inspection report |
| ULP-B | Unlicensed Personnel | Named in medication administration and background study deficiencies |
| ULP-E | Unlicensed Personnel | Named in background study and annual training deficiencies |
| ULP-G | Unlicensed Personnel | Named in medication administration competency deficiency |
| RN-D | Registered Nurse | Named in infection control and medication administration findings |
| LALD-C | Licensed Assisted Living Director | Named in multiple findings including staffing and emergency preparedness |
| BOC-J | Business Office Coordinator | Named in employee record and training documentation deficiencies |
| ULP-F | Unlicensed Personnel | Named in awake staff deficiency |
| ULP-I | Unlicensed Personnel | Named in infection control and catheter care findings |
| ULP-L | Unlicensed Personnel | Named in catheter care training deficiency |
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