Lino Lakes Gw

Survey completed January 18, 2023: 7 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, and the United States Department of Agriculture (USDA) guidelines.

  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, and the United States Department of Agriculture (USDA) guidelines. This had the potential to affect all residents of the assisted living with dementia care facility. [...]”

  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 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

  MDH’s finding, as written: “Based on interview and record review the licensee failed to have a written emergency preparedness (EP) plan with all the required content as defined in Appendix Z. 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 a widespread scope (when problems are pervasive or represent a systemic [...]”

  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 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 develop a fire safety and evacuation plan with required elements; failed to provide required employee training on fire safety and evacuation; failed to provide training to residents capable of assisting in their own evacuation and failed to conduct required evacuation drills.

  MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop a fire safety and evacuation plan with required elements; failed to provide required employee training on fire safety and evacuation; failed to provide training to residents capable of assisting in their own evacuation and failed to conduct required evacuation drills. 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 950: 144.50 Subd. 3 Designation of representative Level 2, isolated scope, scope/level letter D · correction period: Twenty-One (21) days
  Details

  Summary: MDH found the licensee failed to offer the opportunity to identify a designated representative, on a separate form, including statutory language, for two of three residents (R3, R4).

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to offer the opportunity to identify a designated representative, on a separate form, including statutory language, for two of three residents (R3, R4). [...]”

  Rule cited: “(a) Before or at the time of execution of an assisted living contract, an assisted living facility must offer the resident the opportunity to identify a designated representative in writing in the contract and must provide the following verbatim notice on a [...]”

• Tag 1760: 144G.71 Subd. 8 Documentation of administration of medication Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure accurate documentation of medication administration for one of three residents (R3).

  MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure accurate documentation of medication administration for one of three residents (R3). 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 an isolated scope (when one or a limited number of residents are affected or one or a limited number of staff are involved, or the [...]”

  Rule cited: “Each medication administered by the assisted living facility staff must be documented in the resident's record. The documentation must include the signature and title of the person who administered the medication. [...]”

• Tag 1890: 144G.71 Subd. 20 Prescription drugs Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure medications were maintained, including the opened date for time sensitive medication storage for two of three residents (R2, R3).

  MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure medications were maintained, including the opened date for time sensitive medication storage for two of three residents (R2, R3). [...]”

  Rule cited: “A prescription drug, prior to being set up for immediate or later administration, must be kept in the original container in which it was dispensed by the pharmacy bearing the original prescription label with legible information including the expiration or [...]”

• Tag 2040: 144G.81 Subdivision 1 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 hazard vulnerability assessment or safety risk assessment of the physical environment on and around the property for the facility.

  MDH’s finding, as written: “Based on record review and interview, the licensee failed to provide hazard vulnerability assessment or safety risk assessment of the physical environment on and around the property for the facility. This deficient practice had the ability to affect all staff, residents, and visitors. [...]”

  Rule cited: “An assisted living facility with dementia care that has a secured dementia care unit must meet the requirements of section 144G.45 and the following additional requirements: (1) a hazard vulnerability assessment or safety risk must be performed on and around [...]”

From MDH’s letter: no immediate fines.

Allegation, as written: “The facility neglected a resident when staff failed to administer scheduled medications as ordered by the resident's physician.”

“The Minnesota Department of Health determined neglect was inconclusive.”

Summary: MDH looked into an allegation and found: neglect inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was inconclusive. It is unable to be determined if the error caused additional medical complications for the resident. Although a medication error occurred, blood glucose readings obtained following the error remained within acceptable parameters provided by the resident's physician. When a high blood glucose reading was obtained the following evening, staff immediately reported the reading to the nurse, contacted emergency medical services (EMS) and the resident was transferred to the hospital for further evaluation and treatment.”

Action taken by facility: “The facility worked with the software vendor to correct the issue and obtained new computer equipment. Staff members involved were re-trained and counseled on facility policies and procedures.”

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

Survey completed November 21, 2022: 1 correction order

• Tag 1760: 144G.71 Subd. 8 Documentation of administration of medication Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure medications were administered as ordered for one of three residents (R1) with records reviewed.

  MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure medications were administered as ordered for one of three residents (R1) with records reviewed. [...]”

  Rule cited: “Each medication administered by the assisted living facility staff must be documented in the resident's record. The documentation must include the signature and title of the person who administered the medication. [...]”

Allegation, as written: “The alleged perpetrator (AP) neglected the resident when the resident did not receive medication according to physician orders and the resident was hospitalized.”

“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 received a different resident's medications, the error was an isolated incident and the facility provided timely care in response to the error. The resident's blood pressure and pulse decreased, and the resident was sent to the hospital. The resident required placement of a pacemaker, (a medical device that uses electrical pulses to regulate the heart's rhythm, correcting slow, fast, or irregular heartbeats by prompting the heart to contract and pump blood effectively). A physician stated the resident had a history of atrial fibrillation (an irregular heartbeat) and would have needed a pacemaker placed to ensure the heart rate was within normal range of 60 to 100 beats per minute.”

Action taken by facility: “Following the medication error, the resident's vital signs were monitored, and the resident was sent to the hospital. The AP was educated on the medication error and the facility's medication administration policy and was removed from medication administration.”

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

Survey completed January 6, 2026: no correction orders issued.

Allegation, as written: “The facility neglected the resident when, after multiple falls and injuries, the facility did not develop interventions to prevent future falls.”

“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 had multiple falls, facility staff reported, assessed, monitored, treated and developed post-fall preventative measures after each fall reviewed. The resident's providers and family were notified of each fall.”

Action taken by facility: “The facility completed facility incident reports. The facility reported all falls to the resident's provider, family and hospice agency. The facility completed post-fall reviews and initiated fall prevention interventions after each fall. The resident was assessed, monitored and treated after each fall. The facility completed assessments after falls and changes in condition when applicable.”

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

Survey completed November 6, 2025: no correction orders issued.

Survey completed February 26, 2025: no correction orders issued.