Inver Grove Heights Wp II

Survey completed January 20, 2022: 11 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: (i) at least three nutritious meals daily with snacks available seven days per week, according to the recommended dietary allowances in the United States Department of [...]”

• Tag 630: 144G.42 Subd. 6 Compliance with requirements for reporting ma Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure an individual abuse prevention plan was developed to include the required content for three of three residents (R1, R3, R4) with records reviewed.

  MDH’s finding, as written: “Based on record review and interview, the licensee failed to ensure an individual abuse prevention plan was developed to include the required content for three of three residents (R1, R3, R4) with records reviewed. [...]”

  Rule cited: “(b) The facility must develop and implement an individual abuse prevention plan for each vulnerable adult. [...]”

• Tag 680: 144G.42 Subd. 10 Disaster planning and emergency preparedness Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to post an emergency plan prominently and develop an emergency preparedness plan with all required content.

  MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to post an emergency plan prominently and develop an emergency preparedness plan with all required content. This had the potential to affect all 38 residents, staff and visitors. [...]”

  Rule cited: “(a) The facility must meet the following requirements: (1) have a written emergency disaster plan that contains a plan for evacuation, addresses elements of sheltering in place, identifies temporary relocation sites, and details staff assignments in the event [...]”

• 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 the client record included a discharge summary for one of one discharged resident (R2) with record reviewed.

  MDH’s finding, as written: “Based on record review and interview, the licensee failed to ensure the client record included a discharge summary for one of one discharged resident (R2) with record 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, [...]”

• Tag 800: 144G.45 Subd. 2 (a) (4) 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 physical environment in a continuous state of good repair and operation regarding the health, safety, and well-being of the residents.

  MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the facility's physical environment in a continuous state of good repair and operation regarding the health, safety, and well-being of the residents. This had the potential to directly affect all residents, staff, and visitors. [...]”

  Rule cited: “(4) keep the physical environment, including walls, floors, ceiling, all furnishings, grounds, systems, and equipment in a continuous state of good repair and operation with regard to the health, safety, comfort, and well-being of the residents in accordance [...]”

From MDH’s letter: no immediate fines.

Allegation, as written: “The facility neglected the resident when they failed to provide wound care and hygiene/toileting assistance. As a result, the resident developed advanced pressure wounds and skin rashes. The resident required hospitalization.”

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

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

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was not substantiated. The resident had chronic, non-healing wounds which required complex wound care management. The facility did not have the capabilities of providing these types of wound cares, but they did coordinate wound care management with an outside agency. Although the resident developed a skin rash in her groin, candida (yeast) caused this. The resident received multiple antibiotic medications prior to the rash. (Antibiotics can cause yeast infections/rash). Additionally, the facility regularly communicated with the resident's physician about her wounds and health decline.”

Action taken by facility: “The facility coordinated the resident's medical care with her medical providers.”

Action taken by MDH: “No further action taken at this time.”

Survey completed November 25, 2025: no correction orders issued.

Allegation, as written: “The alleged perpetrator/facility unlicensed personnel neglected the resident when they failed to provide physical safety and implement fall precautions. The resident fell and required hospitalization for a left leg fracture.”

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

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

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was not substantiated. Although the resident fell and sustained a hip fracture, there was not a preponderance of evidence to support that the actions of the facility staff met the definition of neglect.”

Action taken by facility: “The facility staff provided immediate assistance and contacted emergency medical services. The resident was admitted to the hospital for care. The facility investigated the incident and required staff to attend additional training.”

Action taken by MDH: “No further action at this time.”

Survey completed April 17, 2025: no correction orders issued.