Inspection Reports for Upend Home Health Care
1698 Beech Street, St. Paul, MN 55106, MN, 55106
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Inspection Report
Follow-Up
Census: 3
Deficiencies: 14
Nov 25, 2024
Visit Reason
Follow-up survey conducted to determine if orders from the August 15, 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: 11
Level 3: 3
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to develop and implement a staffing plan with biannual RN evaluation. | Level 2 |
| Failed to ensure food was prepared and served according to Minnesota Food Code. | Level 2 |
| Failed to develop individual abuse prevention plans with required content for two residents. | Level 2 |
| Employee records lacked current job descriptions and annual performance reviews for two employees. | Level 2 |
| Failed to maintain a written emergency preparedness plan with all required content. | Level 2 |
| Failed to provide smoke alarms that complied with fire protection requirements including interconnection. | Level 2 |
| Physical environment not maintained in good repair: loose railing, disconnected dryer vent, daisy-chained power strips, egress window operator arm disconnected. | Level 2 |
| Failed to develop and maintain a fire safety and evacuation plan with required content; failed to provide required training and drills. | Level 2 |
| Egress windows in resident bedrooms did not meet minimum size requirements and were obstructed by hardware. | Level 3 |
| Back door exit had a key-only lock limiting safe egress. | Level 3 |
| Failed to submit plan review applications and obtain permits for installation of egress windows in resident bedrooms. | Level 2 |
| Failed to ensure background study was current for one employee; expired COVID-19 emergency background study not replaced. | Level 3 |
| Resident service plan lacked schedule and methods of monitoring assessments and staff, contingency plan including contact information and emergency notification. | Level 2 |
| Failed to document disposition of medications for discharged resident including medication details and staff involved. | Level 2 |
Report Facts
Residents present: 3
Fine amount: 3000
Egress window clear area: 651
Egress window clear area: 774
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| ULP-B | Unlicensed Personnel | Named in background study expired finding and medication administration. |
| ULP-D | Unlicensed Personnel | Named in employee record missing documentation finding. |
| O/CNS/LALD-C | Owner/Clinical Nurse Supervisor/Licensed Assisted Living Director | Named in multiple findings including staffing plan, background study, abuse prevention plan, emergency preparedness, and medication disposition. |
| O/A-A | Owner/Agent | Named in multiple findings including staffing plan, background study, emergency preparedness, fire safety, and medication disposition. |
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