Lake Minnetonka Shores (Independent Living and Assisted Living and Memory Care)

Survey completed August 4, 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 800: 144G.45 Subd. 2 (a) (4) Fire protection and physical environment Level 2, isolated scope, scope/level letter D · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to maintain 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.

  MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain 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. This deficient condition had the ability to affect a limited number of staff and residents. [...]”

  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 [...]”

• 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 provide specific elements within their fire safety and evacuation plan and required employee training on fire safety and evacuation.

  MDH’s finding, as written: “Based on record review and interview, the licensee failed to provide specific elements within their fire safety and evacuation plan and required employee training on fire safety and evacuation. This had the potential to affect all staff, residents, and visitors. [...]”

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

• Tag 1060: 144G.52 Subd. 9 Emergency relocation Level 2, isolated scope, scope/level letter D · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to provide a written notice with the required content for an emergency relocation to the resident, legal representative, or designated representative, and the Office of Long-Term Care (OOLTC) for one of one resident (R2) who had an emergency relocation.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a written notice with the required content for an emergency relocation to the resident, legal representative, or designated representative, and the Office of Long-Term Care (OOLTC) for one of one resident (R2) who had an emergency relocation. [...]”

  Rule cited: “(a) A facility may remove a resident from the facility in an emergency if necessary due to a resident's urgent medical needs or an imminent risk the resident poses to the health or safety of another facility resident or facility staff member. [...]”

From MDH’s letter: no immediate fines.

Allegation, as written: “The resident was financially exploited by drug diversion when the alleged perpetrator (AP) tampered with and diverted 6 narcotic hydrocodone-acetaminophen tablets (Norco) for her own use and replaced them with another non-controlled medication.”

“The Minnesota Department of Health determined financial exploitation by drug diversion by the AP was inconclusive.”

Summary: MDH looked into an allegation and found: financial exploitation by drug diversion by the AP inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined financial exploitation by drug diversion by the AP was inconclusive. The resident's Norco was tampered with and diverted in a time frame of 6 days, during that time at least 12 other staff had access to the medication. As a result, it could not be determined if the AP or another staff tampered with and diverted the resident's Norco.”

Action taken by facility: “The facility reported the potential diversion, investigated the incident, re-educated all staff to identify and report potential diversion, and nursing audits of controlled drug counts were increased to prevent recurrence.”

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

Survey completed September 25, 2024: no correction orders issued.