Inspection Reports for Willows Landing
9872 Hart Blvd, Monticello, MN 55362, United States, MN, 55362
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Inspection Report
Annual Inspection
Census: 86
Deficiencies: 11
Jan 24, 2025
Visit Reason
The Minnesota Department of Health conducted a full survey to evaluate and assess compliance with state licensing statutes for Willows Landing Senior Living.
Findings
The facility was found to be in substantial compliance but had multiple deficiencies including failure to post staffing plans publicly, food service violations, tuberculosis prevention program deficiencies, emergency preparedness plan gaps, fire safety code violations, incomplete staff supervision documentation, delayed resident assessments, incomplete medication assessments, expired medications, and unsecured oxygen tank storage.
Severity Breakdown
Level 2: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to post the required staffing plan in a central location accessible to staff, residents, volunteers, and the public. | Level 2 |
| Failed to ensure food was prepared and served according to the Minnesota Food Code. | Level 2 |
| Failed to establish and maintain a tuberculosis prevention and control program based on current CDC guidelines, including timely annual TB risk assessments. | Level 2 |
| Failed to develop a written emergency preparedness plan with all required content and failed to review the missing resident policy quarterly. | Level 2 |
| Failed to keep the facility in compliance with the Minnesota Fire Code including propped open fire rated door, unsecured kitchen gas equipment, use of extension cords, open electrical panel spaces, lack of compliant egress control locking system in dementia care area, and locked exit door without proper approval. | Level 2 |
| Failed to provide fire safety and evacuation training documentation for employees at new hire and semi-annually and for residents annually. | Level 2 |
| Failed to ensure registered nurse conducted direct supervision of staff performing delegated nursing tasks within 30 days of providing services. | Level 2 |
| Failed to conduct resident admission assessments and reassessments within required timeframes and failed to conduct ongoing nursing assessments not to exceed every 90 days. | Level 2 |
| Failed to ensure registered nurse conducted individualized medication assessment with required content prior to providing medication management services. | Level 2 |
| Failed to monitor for expired medications; expired acetaminophen and stool softener found in resident medication supply. | Level 2 |
| Failed to provide appropriate care related to secure storage of portable oxygen tanks; tanks were stored unsecured in resident bedroom. | Level 2 |
Report Facts
Resident census: 86
Days between resident assessments: 94
Days between resident assessments: 97
Days between resident assessments: 91
Days late for 14-day assessment: 17
Expired medication date: 2024.0917
Temperature: 39
Temperature: 38
Temperature: 181
Temperature: 38
Temperature: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Thorson | Supervisor, State Evaluation Team | Signed the cover letter for the inspection report |
| Susan Winkelmann | Contact for questionnaire | Contact person for provider feedback questionnaire |
| Linda Heinen | Public Health Sanitarian | Signed the Food and Beverage Establishment Inspection Report |
| Jaclyn Hemingsen | Certified Food Protection Manager | Named on Food and Beverage Establishment Inspection Report |
| Kelly Thorson | Supervisor, State Evaluation Team | Named as contact on cover letter |
| Vice President of Operations B | Vice President of Operations | Interviewed regarding TB risk assessment and staff supervision |
| Director of Nursing A | Director of Nursing | Interviewed regarding resident assessments, medication assessments, and expired medications |
| Maintenance Coordinator C | Maintenance Coordinator | Interviewed regarding fire safety deficiencies |
| Unlicensed Personnel D | Unlicensed Personnel | Observed assisting resident and medication audit |
| Licensed Practical Nurse F | Licensed Practical Nurse | Completed medication/treatment assessment improperly |
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