Inspection Report
Follow-Up
Census: 37
Deficiencies: 16
Sep 12, 2025
Visit Reason
Follow-up survey to determine correction of orders from the survey completed on June 26, 2025.
Findings
The follow-up survey verified that the facility is in substantial compliance. The previous survey identified multiple deficiencies including failure to develop and execute a plan of correction, staffing plan issues, food service violations, staff record deficiencies, emergency preparedness gaps, training and supervision failures, incomplete resident assessments, and fire safety code violations.
Severity Breakdown
Level 1: 2
Level 2: 13
Level 3: 1
Deficiencies (16)
| Description | Severity |
|---|---|
| Failed to develop and execute a plan of correction for multiple correction orders from previous routine survey. | Level 2 |
| Failed to update staffing plan at least twice annually. | Level 2 |
| Failed to ensure food was prepared and served according to Minnesota Food Code. | Level 2 |
| Failed to establish and maintain an infection control program consistent with CDC guidelines; observed improper hand hygiene during medication administration. | Level 2 |
| Failed to maintain complete staff records including annual performance reviews. | Level 2 |
| Failed to conduct tuberculosis symptom screening for one employee. | Level 2 |
| Failed to develop a comprehensive written emergency preparedness plan with required content and training. | Level 2 |
| Failed to ensure facility assessments, records, and employee files were readily available for timely access. | Level 2 |
| Failed to comply with Minnesota State Fire Code including controlled egress door locking system, smoking material disposal, emergency exit sign maintenance, electrical outlet covers, and smoke alarm installation. | Level 2 |
| Failed to develop site-specific fire safety and evacuation plan, provide required training and drills to staff and residents. | Level 2 |
| Failed to ensure background study clearance for one employee with expired COVID background study. | Level 3 |
| Failed to ensure training and competency evaluations were completed for all required skill areas prior to providing services for two unlicensed personnel. | Level 2 |
| Failed to ensure required orientation topics were completed for two unlicensed personnel prior to providing services. | Level 2 |
| Failed to ensure employees completed required annual training including maltreatment reporting, infection control, dementia care, and person-centered planning. | Level 2 |
| Failed to ensure registered nurse conducted comprehensive admission, 14-day, and 90-day assessments for two residents. | Level 2 |
| Failed to ensure unlicensed personnel were trained and demonstrated competency by a registered nurse prior to providing treatments including vital signs and TED hose. | Level 2 |
Report Facts
Residents present: 37
Priority 1 orders: 2
Priority 3 orders: 4
Chlorine sanitizer ppm: 0
Lactic acid sanitizer ppm: 0
Dish machine temperature: 168
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| ULP-B | Unlicensed Personnel | Named in findings for lack of competency training, orientation, annual training, RN supervision, dementia training, and treatment training |
| ULP-C | Unlicensed Personnel | Named in findings for lack of competency training, orientation, annual training, RN supervision, dementia training, and treatment training |
| C-F | Cook | Named in finding for background study clearance expired and not renewed |
| ULP-G | Unlicensed Personnel | Named in infection control deficiency for improper hand hygiene during medication administration |
| Renee L. Anderson | Supervisor, State Evaluation Team | Signed follow-up survey letter |
| Casey DeVries | Supervisor, State Evaluation Team | Signed survey letter |
| Dave Dohanick | Culinary Director | Participated in Food & Beverage inspection |
| Sarah Conboy | Public Health Sanitarian Supervisor | Participated in Food & Beverage inspection |
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