Deficiencies per Year
12
9
6
3
0
High
Inspection Report
Routine
Census: 79
Deficiencies: 10
Jun 5, 2025
Visit Reason
The Minnesota Department of Health conducted a survey on June 5, 2025, to evaluate and assess compliance with state licensing statutes for The Waters of Highland Park assisted living facility.
Findings
The licensee was found to be in substantial compliance but had several deficiencies including food service violations, failure to timely report suspected maltreatment, incomplete employee records, missing background study affiliation, lack of 30-day supervision documentation for delegated nursing tasks, unsigned service plans, incomplete medication self-administration assessments, missing dementia care policy acknowledgements, improper oxygen cylinder storage, and fire safety code violations.
Severity Breakdown
Level 2: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Food was not prepared and served according to the Minnesota Food Code, including a missing hand soap at a handwashing sink. | Level 2 |
| Failure to immediately report an incident of suspected maltreatment to the Minnesota Adult Abuse Reporting Center within 24 hours. | Level 2 |
| Employee records lacked documentation of medication administration competency evaluation for one unlicensed personnel. | Level 2 |
| Background study was not submitted and received in affiliation with the assisted living license for one employee. | Level 2 |
| Registered nurse did not conduct direct supervision of staff performing delegated tasks within 30 days for two employees. | Level 2 |
| Current written service plan lacked signature or authentication by the facility and resident documenting agreement on services to be provided. | Level 2 |
| Registered nurse failed to assess and document self-administration of medications in the resident record for one resident. | Level 2 |
| Policies and procedures for assisted living with dementia care were not provided to resident or representative at time of move-in. | Level 2 |
| Oxygen cylinders were improperly stored unsecured and lying on the floor, posing a safety risk. | Level 2 |
| Fire safety violations including disconnected dryer ventilation with lint buildup, obstructed sprinkler head, use of extension cords as permanent wiring, and missing sprinkler escutcheon. | Level 2 |
Report Facts
Residents present: 79
Priority 2 Orders: 1
Monthly charge: 5100
Monthly charge: 6300
Oxygen cylinders: 10
Dish machine temperature: 164
Dish machine temperature: 161
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| ULP-F | Unlicensed Personnel | Named in findings for missing medication competency evaluation and lack of 30-day supervision |
| ULP-G | Unlicensed Personnel | Named in findings for lack of 30-day supervision |
| ULP-C | Unlicensed Personnel | Named in findings for missing background study affiliation and assisting resident with care |
| Renee Anderson | Supervisor, State Evaluation Team | Signed letter transmitting the survey report |
| Greg Nelson | Public Health Sanitarian 3 | Signed Food & Beverage Inspection Report |
| Christian Erickson | Certified Food Protection Manager | Named as CFPM in Food & Beverage Inspection Report |
| LALD-A | Licensed Assisted Living Director | Interviewed regarding multiple findings including employee records, supervision, service plans, and background studies |
| CNS-B | Clinical Nurse Supervisor | Interviewed regarding maltreatment reporting and medication self-administration assessment |
| RN-E | Regional Registered Nurse | Interviewed regarding background study affiliation oversight |
| RMD-D | Regional Maintenance Director | Interviewed regarding fire safety deficiencies |
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