Inspection Reports for Upend Home Health Care

1698 Beech Street, St. Paul, MN 55106, MN, 55106

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Inspection Report Summary

The most recent inspection on November 25, 2024, identified multiple deficiencies related to staffing plans, food preparation, abuse prevention, employee records, emergency preparedness, fire safety, physical environment maintenance, and documentation. Earlier inspections showed similar issues with compliance, and this follow-up survey confirmed that previous correction orders were substantially met, though several areas still required attention. Inspectors cited recurring themes involving safety measures such as fire alarms and egress windows, staff training and evaluation, and proper documentation of resident care and medication handling. No fines, enforcement actions, or complaint investigations were listed in the available reports. The pattern suggests ongoing challenges in meeting regulatory requirements, with some progress noted but additional improvements needed.

Deficiencies (last 1 years)

Deficiencies (over 1 years) 14 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

259% worse than Minnesota average
Minnesota average: 3.9 deficiencies/year

Deficiencies per year

16 12 8 4 0
2024

Inspection Report

Follow-Up
Census: 3 Deficiencies: 14 Date: 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.

Deficiencies (14)
Failed to develop and implement a staffing plan with biannual RN evaluation.
Failed to ensure food was prepared and served according to Minnesota Food Code.
Failed to develop individual abuse prevention plans with required content for two residents.
Employee records lacked current job descriptions and annual performance reviews for two employees.
Failed to maintain a written emergency preparedness plan with all required content.
Failed to provide smoke alarms that complied with fire protection requirements including interconnection.
Physical environment not maintained in good repair: loose railing, disconnected dryer vent, daisy-chained power strips, egress window operator arm disconnected.
Failed to develop and maintain a fire safety and evacuation plan with required content; failed to provide required training and drills.
Egress windows in resident bedrooms did not meet minimum size requirements and were obstructed by hardware.
Back door exit had a key-only lock limiting safe egress.
Failed to submit plan review applications and obtain permits for installation of egress windows in resident bedrooms.
Failed to ensure background study was current for one employee; expired COVID-19 emergency background study not replaced.
Resident service plan lacked schedule and methods of monitoring assessments and staff, contingency plan including contact information and emergency notification.
Failed to document disposition of medications for discharged resident including medication details and staff involved.
Report Facts
Residents present: 3 Fine amount: 3000 Egress window clear area: 651 Egress window clear area: 774

Employees mentioned
NameTitleContext
ULP-BUnlicensed PersonnelNamed in background study expired finding and medication administration.
ULP-DUnlicensed PersonnelNamed in employee record missing documentation finding.
O/CNS/LALD-COwner/Clinical Nurse Supervisor/Licensed Assisted Living DirectorNamed in multiple findings including staffing plan, background study, abuse prevention plan, emergency preparedness, and medication disposition.
O/A-AOwner/AgentNamed in multiple findings including staffing plan, background study, emergency preparedness, fire safety, and medication disposition.

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