Personal Care Senior Living

Survey completed November 8, 2023: 8 correction orders

• Tag 330: 144G.30 Subd. 4 Information provided by facility Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to provide annual inspection reports of the fire sprinkler system and automatic fire alarm system at in a timely fashion.

  MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide annual inspection reports of the fire sprinkler system and automatic fire alarm system at in a timely fashion. This had the potential to directly affect all residents and staff. [...]”

  Rule cited: “(a) The assisted living facility shall provide accurate and truthful information to the department during a survey, investigation, or other licensing activities. [...]”

• 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) 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 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 have a written emergency preparedness plan (EPP) with all the required content.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to have a written emergency preparedness plan (EPP) with all the required content. This had the potential to affect all residents receiving services under the provisional assisted living with dementia care license. [...]”

  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 790: 144G.45 Subd. 2 (a) (2)-(3) 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 portable fire extinguishers.

  MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the portable fire extinguishers. This had the potential to directly affect all residents, staff, and visitors. [...]”

  Rule cited: “(2) install and maintain portable fire extinguishers in accordance with the State Fire Code; (3) install portable fire extinguishers having a minimum 2-A:10-B:C rating within Group R-3 occupancies, as defined by the State Fire Code, located so that the travel [...]”

• 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 complete fire safety and evacuation training with residents and failed to complete the required employee evacuation drills.

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

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

From MDH’s letter: MDH granted the assisted living license; no immediate fines.

Allegation, as written: “The Alleged Perpetrator (AP), facility staff, financially exploited the resident when he stole the resident's narcotic pain medication for personal use.”

“The Minnesota Department of Health determined financial exploitation was inconclusive.”

Summary: MDH looked into an allegation and found: financial exploitation inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined financial exploitation was inconclusive. The resident said she did not receive her pain medication (hydrocodone) one evening when the AP was working; and also stated there were multiple other times she did not receive her hydrocodone when she requested it. A nurse who reviewed video footage said she saw the AP ingest the resident's hydrocodone. An administrator who reviewed the same video footage said she did not see the AP ingest the hydrocodone. The video was not available for investigator review. It could not be determined if an inconsistency in documentation between the resident's electronic medication administration record (eMAR) and the narcotic count logbook were the result of deliberate medication diversion or a documentation error. The AP denied the allegation.”

Action taken by facility: “The AP is no longer employed by the facility.”

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

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

Allegation, as written: “The facility and the alleged perpetrator (AP) neglected the resident when facility staff found the resident face down on the floor with medical equipment on top of her. The resident had bleeding on her hand and vomited. Emergency medical services (EMS) transferred the resident to the hospital. The AP left the facility before staff found the resident on the floor and did not return.”

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

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

Summary: MDH looked into 2 allegations and found: neglect not substantiated; neglect not substantiated.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was not substantiated. The resident did not fall from a mechanical lift but fell from a power lift chair onto the floor. An error in therapeutic conduct occurred by failing to assess and implement an intervention to help prevent the resident from inadvertently pressing the chair's remote. However, the resident did not require significant medical intervention or treatment. The Minnesota Department of Health determined neglect was not substantiated against the AP. The AP left the facility before the resident fell, and only left after a miscommunication between her and facility staff.”

Action taken by facility: “The facility completed an internal investigation and implemented the intervention of keeping the remote out of the resident's reach while in the power lift chair.”

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

Survey completed May 21, 2024: no correction orders issued.

Allegation, as written: “The facility neglected the resident when the resident fell, and the facility did not send the resident to the hospital until almost one week later. The resident went to the hospital and was diagnosed with a head injury.”

“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 did not go to the emergency department (ED) until one week later, the facility monitored him after the fall and provided pain medication as needed. Hospital records showed there was not an injury to correlate to the blood found with imaging in the brain.”

Action taken by facility: “The facility monitored the resident, provided ice and over the counter pain medication, and stayed in contact with the family. The facility also sent the resident into the hospital when he requested.”

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

Survey completed May 21, 2024: no correction orders issued.