Inspection Report
Annual Inspection
Census: 206
Capacity: 210
Deficiencies: 16
Jul 13, 2023
Visit Reason
The Minnesota Department of Health conducted a survey to evaluate and assess compliance with state licensing statutes for The Pillars of Prospect Park.
Findings
The survey identified multiple violations including failure to obtain accurate licensure for an innovation variance related to student housing, failure to ensure food was prepared and served according to Minnesota Food Code, failure to maintain an infection control program, incomplete tuberculosis testing for student residents, incomplete documentation of services provided, lack of required fire safety training for employees, failure to submit background studies for student residents, incomplete orientation and dementia care training for student residents, failure to conduct timely resident reassessments, incomplete medication prescriptions, unsecured medication storage, incomplete treatment management plans, and improper use and assessment of bed rails.
Severity Breakdown
Level 2: 13
Level 3: 2
Deficiencies (16)
| Description | Severity |
|---|---|
| Failed to obtain accurate licensure for innovation variance related to student housing. | 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 accepted standards. | Level 2 |
| Failed to ensure tuberculosis testing was completed for 11 student residents. | Level 2 |
| Failed to document services provided as identified in the service plan for three residents. | Level 2 |
| Failed to provide required employee training on fire safety and evacuation twice per year. | Level 2 |
| Failed to ensure background studies were submitted and received for 11 student residents. | Level 3 |
| Failed to ensure student residents completed required orientation before providing volunteer services. | Level 2 |
| Failed to ensure employees who do not provide direct care received required dementia care training within 160 working hours of employment. | Level 2 |
| Failed to conduct ongoing resident monitoring and reassessment within 90 days for three residents. | Level 2 |
| Failed to ensure incomplete medication prescriptions were clarified for two residents. | Level 2 |
| Failed to lock medication storage cart while unattended on secured memory care unit. | Level 2 |
| Failed to develop and implement individualized treatment or therapy management plan for one resident. | Level 2 |
| Failed to provide hazard vulnerability assessment with mitigation factors for physical environment. | Level 2 |
| Limited resident rights by removing a grab bar without RN assessment or resident/representative consultation. | Level 2 |
| Failed to provide care and services according to accepted health care standards for two residents using consumer bed rails. | Level 3 |
Report Facts
Residents present: 206
Total licensed capacity: 210
Fines assessed: 6500
Student residents: 11
Missed documentation counts: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Casey DeVries | Supervisor, State Evaluation Team | Signed letter regarding survey and fines |
| Jerry Malloy | Sanitarian Supervisor | Signed food and beverage inspection report |
| Jeremy Switzer | Certified Food Protection Manager | Signed food and beverage inspection report |
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