Inspection Report
Routine
Census: 84
Capacity: 64
Deficiencies: 14
Mar 12, 2025
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 survey identified multiple deficiencies including unauthorized use of facility space by a third party vendor, lack of required policies and procedures, infection control lapses, fire safety code violations, physical environment disrepair, contract language waiving liability, incomplete service plans, medication management issues, and lack of individualized activity plans for residents with dementia.
Severity Breakdown
Level 1: 1
Level 2: 13
Deficiencies (14)
| Description | Severity |
|---|---|
| Licensee allowed use of facility space by a third party vendor to provide beautician services to outside community members. | Level 2 |
| Licensee failed to have current policies and procedures including supervision of nurses and licensed health professionals. | Level 2 |
| Failed to establish and maintain an infection control program; staff failed to perform hand hygiene after perineal care and glove removal. | Level 2 |
| Failed to comply with Minnesota State Fire Code including improper use of extension cords, disconnected fire door closer, and missing oxygen signage. | Level 2 |
| Failed to maintain physical environment in good repair; water leaking from light fixture in resident unit. | Level 2 |
| Assisted living contract included waiver of liability clause for health, safety, or personal property of residents. | Level 1 |
| Service plans lacked required notice that RN would complete assessment of physical and cognitive needs prior to contract execution or move-in. | Level 2 |
| Medication management policies lacked education of residents and representatives about medications. | Level 2 |
| Failed to document medication administration as required; crushed medications that should not have been crushed. | Level 2 |
| Failed to develop written procedures for unlicensed personnel administering medications during unplanned time away including notification and documentation requirements. | Level 2 |
| Failed to date time sensitive medications when opened (e.g., insulin pen). | Level 2 |
| Failed to document disposition of medications upon resident discharge. | Level 2 |
| Failed to develop individualized activity plans based on resident evaluations for residents with dementia. | Level 2 |
| Unlicensed personnel failed to follow appropriate medication administration procedures by leaving medication in resident's room. | Level 2 |
Report Facts
Residents present: 84
Licensed capacity: 64
Correction order timeframes: 21
Correction order timeframes: 7
Dishwasher rinse temperature: 129
Quaternary Ammonia sanitizer concentration: 200
Quaternary Ammonia sanitizer concentration: 400
Food temperatures: 189
Food temperatures: 38
Food temperatures: 38
Food temperatures: 40
Food temperatures: 178
Food temperatures: 39
Food temperatures: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| ULP-D | Unlicensed Personnel | Named in medication administration and infection control deficiencies |
| CNS-A | Clinical Nurse Supervisor | Provided information on policies, procedures, and deficiencies |
| LALD-B | Licensed Assisted Living Director | Signed renewal application worksheet attesting to policies |
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