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/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Follow-Up
Census: 27
Deficiencies: 14
Date: Aug 5, 2025
Visit Reason
Follow-up survey to determine correction of orders found on prior surveys related to licensing and physical environment compliance.
Findings
The facility failed to correct multiple state correction orders related to fire protection, physical environment, and licensing requirements. Deficiencies included unpermitted construction without approved plans and permits, missing fire doors, improper locking mechanisms on exit doors, and failure to maintain the physical environment in good repair. The facility also failed to provide required grievance procedure postings and designate representatives notices. Background studies were incomplete for some staff, and medication administration documentation was deficient.
Deficiencies (14)
Unpermitted construction work including removal of fire rated doors without approved plans and permits.
Physical environment not maintained in continuous state of good repair, including missing fire doors and holes in fire doors.
Improper locking mechanisms on exit doors that could delay egress in emergencies.
Failure to post grievance procedure information with required contact details.
Failure to complete required employee fire evacuation drills twice per year per shift.
Lack of approved building permit and MDH engineering plan approval for renovations.
Failure to provide safety risk assessment or hazard vulnerability assessment of the physical environment with mitigation factors.
Failure to provide required designation of representative notice on a separate document from the contract.
Failure to provide required emergency relocation written notice and notification to Ombudsman.
Background study clearance not completed prior to staff providing services.
Medication administered not as prescribed; applied to wrong body part.
Lack of individualized treatment and therapy management plan with required content.
Failure to provide required dementia care policies and procedures to residents or their representatives at move-in.
Failure to prepare and serve food according to Minnesota Food Code; refrigeration unit out of temperature with hazardous foods discarded.
Report Facts
Fine amount: 3000
Temperature: 46
Temperature: 41
Temperature: -7
Temperature: -1
Resident census: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Benjamin J. Zwart | Supervisor, State Engineering Services Section | Contact for questions regarding correction orders and fines |
| Jodi Johnson | Supervisor, State Evaluation Team | Contact for questions regarding maltreatment reconsideration |
| Tim Hanna | Interim Supervisor, State Engineering Services Section | Contact for questions regarding correction orders and fines |
| Rob Davis | Sanitarian 2, Rochester District Office | Certified Food Protection Manager for food safety inspection |
| Jill Megraw | Certified Food Protection Manager | Certified Food Protection Manager for food safety inspection |
| ULP-F | Unlicensed Personnel | Named in medication administration error and background study violation |
| LALD-A | Licensed Assisted Living Director | Named in multiple findings including construction, fire safety, grievance posting, and policy deficiencies |
| DM-E | Director of Maintenance | Named in physical environment and fire safety findings |
| CNS-B | Clinical Nurse Supervisor | Named in medication administration and emergency relocation findings |
| AA-C | Administrative Assistant | Named in grievance posting finding |
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