Inspection Report
Original Licensing
Census: 71
Deficiencies: 4
May 14, 2024
Visit Reason
The Minnesota Department of Health conducted an initial survey to assess compliance with state licensing statutes for assisted living with dementia care.
Findings
The licensee was found in substantial compliance but had state correction orders issued for deficiencies including infection control, fire safety and physical environment maintenance, and medication storage. The infection control deficiency involved failure to disinfect shared medical equipment. Fire safety deficiencies included malfunctioning trash chute doors and incomplete fire safety and evacuation plans and training. Medication storage deficiencies involved unsecured medications found in a resident's room.
Severity Breakdown
Level 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to establish and maintain an effective infection control program; shared medical equipment not disinfected after use. | Level 2 |
| Failed to maintain physical environment in good repair; trash chute doors did not close and latch properly, and unsafe smoking area ashtray. | Level 2 |
| Failed to develop and maintain complete fire safety and evacuation plans, provide required training and conduct evacuation drills as required. | Level 2 |
| Failed to ensure all medications were securely locked and only accessible to authorized personnel; medications found unsecured in resident's room. | Level 2 |
Report Facts
Residents present: 71
Fine amount: 500
Evacuation drills documented: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Renee Anderson | Supervisor, State Evaluation Team | Signed the licensing notice letter |
| LPN-K | Observed failing to disinfect blood pressure device after use | |
| ULP-L | Unlicensed Personnel | Observed failing to disinfect blood pressure device after use |
| CNS-C | Clinical Nurse Supervisor | Reported shared medical equipment should be disinfected after each use |
| RDM-M | Regional Director of Maintenance | Acknowledged fire safety deficiencies |
| LALD-A | Licensed Assisted Living Director | Provided fire safety and evacuation plan documents and acknowledged deficiencies |
| RD-D | Regional Director | Provided fire safety and evacuation plan documents and acknowledged deficiencies |
| CNS-C | Clinical Nurse Supervisor | Explained medication storage policies and issues |
| ULP-L | Unlicensed Personnel | Stated medications should not be left in resident rooms |
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