Deficiencies (last 1 years)
Deficiencies (over 1 years)
16 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
310% worse than Minnesota average
Minnesota average: 3.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Follow-Up
Census: 37
Deficiencies: 16
Date: 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.
Deficiencies (16)
Failed to develop and execute a plan of correction for multiple correction orders from previous routine survey.
Failed to update staffing plan at least twice annually.
Failed to ensure food was prepared and served according to Minnesota Food Code.
Failed to establish and maintain an infection control program consistent with CDC guidelines; observed improper hand hygiene during medication administration.
Failed to maintain complete staff records including annual performance reviews.
Failed to conduct tuberculosis symptom screening for one employee.
Failed to develop a comprehensive written emergency preparedness plan with required content and training.
Failed to ensure facility assessments, records, and employee files were readily available for timely access.
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.
Failed to develop site-specific fire safety and evacuation plan, provide required training and drills to staff and residents.
Failed to ensure background study clearance for one employee with expired COVID background study.
Failed to ensure training and competency evaluations were completed for all required skill areas prior to providing services for two unlicensed personnel.
Failed to ensure required orientation topics were completed for two unlicensed personnel prior to providing services.
Failed to ensure employees completed required annual training including maltreatment reporting, infection control, dementia care, and person-centered planning.
Failed to ensure registered nurse conducted comprehensive admission, 14-day, and 90-day assessments for two residents.
Failed to ensure unlicensed personnel were trained and demonstrated competency by a registered nurse prior to providing treatments including vital signs and TED hose.
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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