Inver Glen Senior Living

Survey completed June 14, 2023: 4 correction orders

• Tag 480: 144G.41 Subd 1 (13) (i) (B) Minimum requirements Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to ensure food was prepared and served according to the Minnesota Food Code.

  MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure food was prepared and served according to the Minnesota Food Code. This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large portion or all the [...]”

  Rule cited: “(13) offer to provide or make available at least the following services to residents: (B) food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626; and”

• Tag 810: 144G.45 Subd. 2 (b)-(f) Fire protection and physical environment Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to maintain the facility's fire safety and evacuation plan with required elements.

  MDH’s finding, as written: “Based on record review and interview, the licensee failed to maintain the facility's fire safety and evacuation plan with required elements. This had the potential to directly affect all residents, staff, and visitors. [...]”

  Rule cited: “(b) Each assisted living facility shall develop and maintain fire safety and evacuation plans. [...]”

• Tag 1650: 144G.70 Subd. 4 (f) Service plan, implementation and revisions to Level 2, isolated scope, scope/level letter D · correction period: Twenty-One (21) days
  Details

  Summary: MDH found the licensee failed to ensure the service plan included the required content for one of four residents (R5).

  MDH’s finding, as written: “Based on observation interview and record review, the licensee failed to ensure the service plan included the required content for one of four residents (R5). This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to cause serious injury, impairment, or death), and was issued at an isolated scope (when one or a limited number of residents are affected or [...]”

  Rule cited: “(f) The service plan must include: (1) a description of the services to be provided, the fees for services, and the frequency of each service, according to the resident's current assessment and resident preferences; (2) the identification of staff or [...]”

• Tag 2310: 144G.91 Subd. 4 (a) Appropriate care and services Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure the care and services were provided according to a suitable and up-to-date plan, and subject to acceptable health care and medical, or nursing standards with storage of oxygen (O2) cylinders, to prevent tipping or damage, for two of two residents (R1, R2).

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the care and services were provided according to a suitable and up-to-date plan, and subject to acceptable health care and medical, or nursing standards with storage of oxygen (O2) cylinders, to prevent tipping or damage, for two of two residents (R1, R2). [...]”

  Rule cited: “(a) Residents have the right to care and assisted living services that are appropriate based on the resident's needs and according to an up-to-date service plan subject to accepted health care standards.”

From MDH’s letter: no immediate fines.

Allegation, as written: “The AP abused a resident when she forced her to shower against her will. The resident had bruising on her wrists and forearms.”

“The Minnesota Department of Health determined abuse was not substantiated.”

Summary: MDH looked into an allegation and found: abuse not substantiated.

MDH’s conclusion, as written: “The Minnesota Department of Health determined abuse was not substantiated. Although the resident's behavior indicated she did not want to shower, she had a history of yelling out and resisting cares. The resident had dementia (memory loss) and did not have insight into her care needs. The actions of the AP did not meet statute requirements for abuse, and no harm occurred to the resident. Providing a shower was in the best of interest of the resident.”

Action taken by facility: “The facility re-educated staff members on safe transfers and behavior management.”

Action taken by MDH: “The facility was found to be in noncompliance.”

Survey completed February 26, 2025: 1 correction order

• Tag 730: 144G.43 Subd. 3 Contents of resident record Level 2, isolated scope, scope/level letter D · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to ensure resident records had the required content including documentation of incidents involving the resident, assessment of injuries, and actions taken in response to the needs of the resident for one of one resident (R1) reviewed.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure resident records had the required content including documentation of incidents involving the resident, assessment of injuries, and actions taken in response to the needs of the resident for one of one resident (R1) reviewed. [...]”

  Rule cited: “Contents of a resident record include the following for each resident: (1) identifying information, including the resident's name, date of birth, address, and telephone number; (2) the name, address, and telephone number of the resident's emergency contact, [...]”