Deficiencies per Year
20
15
10
5
0
High
Moderate
Inspection Report
Follow-Up
Census: 35
Deficiencies: 20
Oct 23, 2024
Visit Reason
Follow-up survey to determine if orders from the July 24, 2024 survey were corrected.
Findings
The follow-up survey verified that the facility is in substantial compliance with previous correction orders.
Severity Breakdown
Level 2: 17
Level 3: 2
Deficiencies (20)
| Description | Severity |
|---|---|
| Food was not prepared and served according to the Minnesota Food Code, resulting in a level two violation at a widespread scope. | Level 2 |
| Failed to establish and maintain an effective infection control program, including proper cleaning of shared medical equipment and hand hygiene, resulting in a level two violation at a pattern scope. | Level 2 |
| Failed to accurately identify all areas of vulnerability on individual abuse prevention plans for three residents, resulting in a level two violation at a pattern scope. | Level 2 |
| Employee record for one employee lacked documentation of annual performance review, resulting in a level two violation at an isolated scope. | Level 2 |
| Smoke alarms were missing in bedrooms and were not interconnected, resulting in a level two violation at a widespread scope. | Level 2 |
| Failed to maintain physical environment including trash chute and trash room doors that did not close and latch, and master key issues, resulting in a level two violation at a widespread scope. | Level 2 |
| Failed to develop a complete fire safety and evacuation plan, provide required staff training and conduct required evacuation drills, resulting in a level two violation at a widespread scope. | Level 2 |
| Employee (dining director) lacked a cleared Minnesota DHS NETStudy 2.0 background study affiliated with the licensee, resulting in a level three violation at a widespread scope. | Level 3 |
| Agency staff (clinical nurse supervisor) lacked required orientation on person-centered planning/service delivery, resulting in a level two violation at an isolated scope. | Level 2 |
| Two unlicensed personnel lacked required training in multiple areas prior to providing services, resulting in a level two violation at an isolated scope. | Level 2 |
| Failed to ensure registered nurse completed supervision of unlicensed personnel within 30 days of hire and thereafter as needed, resulting in a level two violation at an isolated scope. | Level 2 |
| Two unlicensed personnel lacked required orientation content, resulting in a level two violation at an isolated scope. | Level 2 |
| One unlicensed personnel failed to complete at least eight hours of annual training for each 12 months of employment, resulting in a level two violation at an isolated scope. | Level 2 |
| One unlicensed personnel failed to complete at least eight hours of initial dementia training within 160 working hours of employment, resulting in a level two violation at an isolated scope. | Level 2 |
| Registered nurse failed to conduct initial nursing assessments of physical and cognitive needs prior to move-in for two residents, resulting in a level two violation at an isolated scope. | Level 2 |
| Medication administration was not documented accurately for one resident, resulting in a level two violation at an isolated scope. | Level 2 |
| Medications were not stored according to manufacturer's instructions; medication refrigerator temperature was not monitored, resulting in a level two violation at a widespread scope. | Level 2 |
| Prescriptions were not renewed at least every 12 months for one resident, resulting in a level two violation at an isolated scope. | Level 2 |
| Expired medications were found for two residents, resulting in a level two violation at an isolated scope. | Level 2 |
| Failed to provide care and services according to acceptable health care standards for two residents who utilized consumer bed rails, including lack of documentation of use, maintenance, manufacturer instructions, and safety inspections, resulting in a level three violation at a widespread scope. | Level 3 |
Report Facts
Residents present during survey: 35
Fine amount: 6000
Expired insulin date: 202202
Expired inhaler date: 202404
Dish machine sanitizer concentration: 0
Dish machine sanitizer concentration: 100
Quaternary ammonia sanitizer concentration: 200
Quaternary ammonia sanitizer concentration: 400
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Thanh Le | Food Service Director | Named in food service inspection report |
| Jess Schoenecker | Supervisor, State Evaluation Team | Named in follow-up and initial survey letters |
| Melissa Ramos | Environmental Health Specialist | Named in food service inspection report |
| LALD-A | Licensed Assisted Living Director | Named in multiple findings related to training, supervision, and assessments |
| CNS-B | Clinical Nurse Supervisor | Named in multiple findings related to training, supervision, medication, and assessments |
| DM-C | Director of Maintenance | Named in findings related to fire safety and physical environment |
| ULP-D | Unlicensed Personnel | Named in findings related to training, supervision, medication administration |
| ULP-G | Unlicensed Personnel | Named in findings related to training and infection control |
| DD-E | Dining Director | Named in background study finding |
| ULP-F | Unlicensed Personnel | Named in medication administration and expired medication findings |
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