Northern Oaks Place

Survey completed April 6, 2023: 17 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 485: 144G.41 Subd 1. (13) (i) (A) and (C) Minimum Requirements Level 1, widespread scope, scope/level letter C · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to ensure the Assisted Living contract did not require any resident to include and pay for meals as a part of their assisted living package fee.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the Assisted Living contract did not require any resident to include and pay for meals as a part of their assisted living package fee. This had the potential to affect all residents of the 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 580: 144G.42 Subd. 2 Quality management Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to implement and maintain a quality management program appropriate to the size of the facility and relevant to the type of services provided.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to implement and maintain a quality management program appropriate to the size of the facility and relevant to the type of services provided. This had the potential to affect all current residents, staff, and visitors. [...]”

  Rule cited: “The facility shall engage in quality management appropriate to the size of the facility and relevant to the type of services provided. [...]”

• 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 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 800: 144G.45 Subd. 2 (a) (4) Fire protection and physical environment Level 2, widespread scope, scope/level letter F · correction period: Seven (7) 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 potential to affect all staff, residents, 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: the letter says the facility is in substantial compliance; no immediate fines.

Allegation, as written: “The resident was neglected when the resident fell and was improperly transferred off of the floor by a facility staff member/alleged perpetrator (AP), resulting in the resident's right shoulder being dislocated.”

“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. Although staff did not follow facility protocol when transferring the resident off of the floor following a fall, it was unable to be determined if the resident's right shoulder dislocation was a result of the transfer.”

Action taken by facility: “Staff were re-educated on falls, incident reports and proper procedure for resident transfer with a gait belt.”

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

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

Allegation, as written: “The faci ity neg ected the resident when the resident had a change in condition, was sent to the hospita and was found with an injury of unknown origin.”

“The Minnesota Department of Hea th determined neg ect was not substantiated.”

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

MDH’s conclusion, as written: “The Minnesota Department of Hea th determined neg ect was not substantiated. When staff observed a change in the resident's condition, staff assessed the resident and arranged for the resident to be eva uated at a hospita. The resident's diagnoses inc uded a chronic (ong term) previous hardware fracture with disp acement (joint pushed out of usua p ace) of the resident's right e bow.”

Action taken by facility: “The resident was sent to the hospita when a change in condition was observed.”

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

Survey completed July 15, 2024: no correction orders issued.

Allegation, as written: “An unknown facility staff member sexually abused the resident when the staff member touched the breast of the resident in front of the resident's family members. After some of the family members left, the staff member returned and touched the resident's breast two more times. In addition, the resident had a fall and bruising to both wrists.”

“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. During the investigation an alleged perpetrator (AP) was identified. Although the AP displayed inappropriate behavior by touching the resident's breast, the behavior did not rise to the level of abuse. In addition, while supervised by a facility staff member, the resident fell while walking in the facility. The facility arranged for a wheelchair following the fall.”

Action taken by facility: “Education was provided to the AP about maintaining professional boundaries.”

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

Survey completed April 15, 2024: no correction orders issued.

Allegation, as written: “The facility neglected a resident when the nurse failed to conduct an assessment for a change of condition, and upon the resident's return from the hospital.”

“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 experienced three falls during her first month at the facility, and the staff follow the fall protocol to ensure her well-being. Although the facility could not provide a fall assessment document after each incident, they did have fall incident reports. The resident received proper care and returned to her baseline health condition.”

Action taken by facility: “No action required.”

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

Survey completed October 17, 2023: no correction orders issued.