Inspection Report
Routine
Census: 130
Capacity: 142
Deficiencies: 12
Oct 10, 2024
Visit Reason
The Minnesota Department of Health conducted a full survey to evaluate and assess compliance with state licensing statutes for an assisted living facility with dementia care license.
Findings
The licensee was found in substantial compliance but had multiple deficiencies including failure to ensure food was prepared according to Minnesota Food Code, inadequate infection control practices, failure to post grievance contact information, late reporting of suspected maltreatment, missing emergency 911 posting, contract language waiving liability, incomplete employee orientation and dementia training, incomplete medication delegation instructions, and incomplete medication disposition documentation.
Severity Breakdown
Level 1: 2
Level 2: 10
Deficiencies (12)
| Description | Severity |
|---|---|
| Food was not prepared and served according to the Minnesota Food Code, including thawing frozen fish in vacuum packaging. | Level 2 |
| Failed to establish and maintain an infection control program consistent with accepted standards, including improper hand hygiene after glove removal by staff. | Level 2 |
| Failed to post grievance procedure contact information in a conspicuous place. | Level 2 |
| Failed to immediately report suspected maltreatment incidents to the Minnesota Adult Abuse Reporting Center for three residents. | Level 2 |
| Failed to post the 911 emergency number in common areas and near telephones. | Level 2 |
| Assisted living contract included language waiving facility liability for resident health, safety, or personal property. | Level 1 |
| Failed to ensure one employee (ULP-D) received complete orientation including principles of person-centered planning prior to providing services. | Level 2 |
| Failed to ensure dementia care training requirements were met for one supervisor (RN-E) within 120 working hours. | Level 2 |
| Failed to ensure dementia care training requirements were met for one direct-care employee (ULP-D) within 80 working hours. | Level 2 |
| Failed to ensure PRN medication orders included specific parameters for administration for one resident (R6). | Level 2 |
| Failed to document disposition of medications upon resident discharge for one resident (R7). | Level 2 |
| Failed to provide required dementia care policies and procedures to residents and/or legal representatives at move-in. | Level 1 |
Report Facts
Resident census: 130
Total licensed capacity: 142
Fine amount: 500
Dementia training hours: 6.25
Dementia training hours: 4.25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| ULP-D | Unlicensed Personnel | Named in infection control and dementia training deficiencies |
| RN-E | Registered Nurse | Named in dementia training deficiency |
| LALD-B | Licensed Assisted Living Director | Interviewed about grievance posting and policy distribution |
| CNS-A | Clinical Nurse Supervisor | Interviewed about infection control, maltreatment reporting, and training |
| RDHW-F | Regional Director of Health and Wellbeing | Interviewed about contract liability language |
| Jessie Chenze | Supervisor, State Evaluation Team | Signed cover letter for the inspection report |
| Jeremy LaFond | Chef, Certified Food Protection Manager | Signed food establishment inspection report |
| Crystal Elva | Public Health Sanitarian 3 | Signed food establishment inspection report |
Loading inspection reports...
