New Perspective Cloquet & Barn, Horizon Circle

Survey completed January 6, 2025: 17 correction orders

• Tag 340: 144G.30 Subd. 5 Correction orders Level 3, widespread scope, scope/level letter I · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to have sufficient documentation with actions taken to comply with the immediate correction order for the initial survey completed on November 6, 2024.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to have sufficient documentation with actions taken to comply with the immediate correction order for the initial survey completed on November 6, 2024. [...]”

  Rule cited: “(a) A correction order may be issued whenever the commissioner finds upon survey or during a complaint investigation that a facility, a managerial official, an agent of the facility, or staff of the facility is not in compliance with this chapter. [...]”

• Tag 470: 144G.41 Subdivision 1 Minimum requirements (re-issued) scope/level letter F
  Details

  Rule cited: “(11) develop and implement a staffing plan for determining its staffing level that: (i) includes an evaluation, to be conducted at least twice a year, of the appropriateness of staffing levels in the facility; (ii) ensures sufficient staffing at all times to [...]”

• Tag 480: 144G.41 Subdivision 1 Subd. 1a (a-b) Minimum requirements; required food services (re-issued) scope/level letter F
  Details

  Rule cited: “(a) Except as provided in paragraph (b), food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626. [...]”

• Tag 510: 144G.41 Subd. 3 Infection control program (re-issued) scope/level letter D
  Details

  Rule cited: “(a) All assisted living facilities must establish and maintain an infection control program that complies with accepted health care, medical, and nursing standards for infection control. [...]”

• Tag 680: 144G.42 Subd. 10 Disaster planning and emergency preparedness (re-issued) scope/level letter F
  Details

  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 [...]”

Survey completed November 6, 2024: 16 correction orders

• Tag 470: 144G.41 Subdivision 1 Minimum requirements Level 2, widespread scope, scope/level letter F · correction period: Twenty-One
  Details

  Summary: MDH found the licensee failed to ensure the staffing schedule was posted with the required content.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the staffing schedule was posted with the required content. This had the potential to affect residents, staff, and any visitors. [...]”

  Rule cited: “(11) develop and implement a staffing plan for determining its staffing level that: (i) includes an evaluation, to be conducted at least twice a year, of the appropriateness of staffing levels in the facility; (ii) ensures sufficient staffing at all times to [...]”

• Tag 480: 144G.41 Subd 1 (13) (i) (B) Minimum requirements Level 2, widespread scope, scope/level letter F · correction period: Please refer to the FBEIR for any compliance dates
  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, but was not likely to cause serious injury, impairment, or death), and is issued at a widespread scope (when problems are pervasive or represent a systemic failure that has [...]”

  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 510: 144G.41 Subd. 3 Infection control program Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to establish and maintain an infection control program to comply with accepted health care, medical, and nursing standards for infection control for one of one employee (unlicensed personnel/ULP-C) observed to provide catheter cares.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to establish and maintain an infection control program to comply with accepted health care, medical, and nursing standards for infection control for one of one employee (unlicensed personnel/ULP-C) observed to provide catheter cares. [...]”

  Rule cited: “(a) All assisted living facilities must establish and maintain an infection control program that complies with accepted health care, medical, and nursing standards for infection control. [...]”

• 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 develop a written emergency preparedness plan (EPP) with all the required content defined in Appendix Z. This had the potential to affect residents receiving services under the assisted living license, staff, and visitors.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop a written emergency preparedness plan (EPP) with all the required content defined in Appendix Z. This had the potential to affect residents receiving services under the assisted living license, 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, pattern scope, scope/level letter E · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to ensure the resident record included documentation of incidents involving the resident and actions taken in response to the needs of the resident for two of three residents (R5, R6) with reports to Minnesota Adult Abuse Reporting Center (MAARC).

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the resident record included documentation of incidents involving the resident and actions taken in response to the needs of the resident for two of three residents (R5, R6) with reports to Minnesota Adult Abuse Reporting Center (MAARC). [...]”

  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, [...]”

From MDH’s letter: the letter says the facility is in substantial compliance.

Fines assessed by MDH

• Tag 1290 (144g.60 Subdivision 1 - Background Studies Required): $3,000.00

Total fines assessed, as printed in the letter: $6,000.00.

Total fines assessed, as printed in the letter: $3,000.00.

Allegation, as written: “The alleged perpetrator (AP) abused a resident when she slapped the resident on the arm. She also held the resident's hand up to her mouth and told her to shut up.”

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

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

MDH’s conclusion, as written: “The Minnesota Department of Health determined abuse was inconclusive. The investigation found there was insufficient evidence to determine if abuse occurred.”

Action taken by facility: “The facility immediately suspended the AP, reported the incident, and began an internal investigation. The facility provide the unlicensed caregiver who was present with the AP education on maltreatment reporting. The AP's employment was terminated for unrelated reasons.”

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

State form: no correction orders issued.

Allegation, as written: “The alleged perpetrator (AP), a facility staff member, abused the resident when the AP used a gait belt (secures around waist to assist with transfers and ambulation) to restrain the resident.”

“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. The resident was seen in her wheelchair with a gait belt on; however, the AP was redirected after cares were started for the resident and the gait belt was not intentionally used as a restraint. The resident was able to move freely with her wheelchair if she chose. The error was an isolated incident, and no harm occurred to the resident. The incident did not rise to the level of abuse.”

Action taken by facility: “The facility licensed staff assessed the resident and conducted an internal investigation.”

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

Survey completed March 2, 2026: no correction orders issued.

Survey completed February 24, 2026: no correction orders issued.

Allegation, as written: “The facility neglected the resident when facility staff failed to administer the resident's ordered medications for management of an infectious condition.”

“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 was seen by a clinic provider for an abscess (infection that builds up within tissue in a single location on the body) when the resident denied receiving a new antibiotic. The provider alerted licensed staff at the facility that a new antibiotic was ordered two days prior. When alerted, licensed staff reached out to pharmacy for information about the order and requested a copy. Licensed staff entered the antibiotic order into the resident's electronic medication record and staff administered the antibiotic. There was a two-day delay in the implementation of the new antibiotic order, however, the two missed doses did not cause harm.”

Action taken by facility: “When the facility became aware of the medication order, licensed staff started an internal investigation to review why the order had not been received and processed into the resident's electronic medication record. [...]”

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

Survey completed February 24, 2025: 1 correction order

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

  Summary: MDH found the licensee failed to transcribe physician orders on the electronic medication administration record (EMAR) to ensure medication was administered as prescribed for one of one resident (R1).

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to transcribe physician orders on the electronic medication administration record (EMAR) to ensure medication was administered as prescribed for one of one resident (R1). This failure had the potential to affect all residents that resided at the licensee. [...]”

  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), a staff member, emotionally abused the resident when the AP made a threatening statement that the facility was trying to remove the resident from the facility. In addition, the AP threw wipes at the resident during toileting services while making a derogatory statement. The AP also rushed the resident when the resident walked. The resident felt frightened.”

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

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

MDH’s conclusion, as written: “The Minnesota Department of Health determined emotional abuse was not substantiated. Although the AP's comments and actions were disrespectful and inappropriate, they did not meet the definition of abuse. The resident denied feeling frightened.”

Action taken by facility: “The facility conducted an internal investigation. The AP is no longer employed by the facility.”

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

Survey completed December 9, 2024: no correction orders issued.