Prelude Homes and Services

Survey completed March 21, 2023: 12 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 had the potential to affect all residents of the assisted living facility. [...]”

  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 660: 144G.42 Subd. 9 Tuberculosis prevention and control Level 2, isolated scope, scope/level letter D · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to establish and maintain a tuberculosis (TB) prevention program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which includes baseline testing, and training for one of three employees (unlicensed personnel (ULP)-D).

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to establish and maintain a tuberculosis (TB) prevention program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which includes baseline testing, and training for one of three employees (unlicensed personnel (ULP)-D). [...]”

  Rule cited: “(a) The facility must establish and maintain a comprehensive tuberculosis infection control program according to the most current tuberculosis infection control guidelines issued by the United States Centers for Disease Control and Prevention (CDC), Division [...]”

• 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 disaster plan with all required content.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to have a written emergency disaster plan with all required content. This had the potential to affect all fifty two (52) residents receiving assisted living services, 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 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 have fire safety and evacuation plans with the required elements and failed to conduct the required drills.

  MDH’s finding, as written: “Based on record review and interview, the licensee failed to have fire safety and evacuation plans with the required elements and failed to conduct the required drills. These deficient practices had the ability 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: 144G.50 Subd. 3 Designation of representative Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to offer the resident the opportunity to identify a designated representative in writing by not requiring the contract section to be filled out, for three of four residents (R2, R4, R5).

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to offer the resident the opportunity to identify a designated representative in writing by not requiring the contract section to be filled out, for three of four residents (R2, R4, R5). [...]”

  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 [...]”

From MDH’s letter: no immediate fines.

Allegation, as written: “The alleged perpetrator (AP) abused the resident when the AP made a gestured threat to "body slam" the resident.”

“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. Although the AP, an unlicensed caregiver, made inappropriate comments and gestures during a conversation with a co-worker, it is unclear if the AP realized the resident was present.”

Action taken by facility: “The facility suspended the AP while investigating the incident. At the time of the investigation, the AP was no longer employed at the facility.”

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

Survey completed March 10, 2026: no correction orders issued.

Allegation, as written: “The facility neglected the resident when staff failed to report a change in condition when the resident was found unresponsive. The alleged perpetrator (AP)/facility staff member abused the resident when the AP grabbed the resident's ankles to put him back into bed.”

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

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

Summary: MDH looked into 2 allegations and found: neglect inconclusive; abuse inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was inconclusive. It is unable to be determined if the actions or inactions of facility staff contributed to the resident's change in condition. The resident was treated at a local hospital and returned to his baseline health condition. The Minnesota Department of Health determined abuse was inconclusive. Although the AP transferred the resident inappropriately, the error in procedure was an isolated incident and the resident returned to their baseline condition.”

Action taken by facility: “The facility retrained the AP and conducted additional competency testing prior to the AP returning to work. The facility also completed a focused review of the resident's care plan, as well as review of the facility policies and procedures pertaining to falls, repositioning, transfers, and assistance with ambulation.”

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

Survey completed May 31, 2024: no correction orders issued.

Allegation, as written: “The facility neglected a resident when the resident received an injury of unknown source to her left arm. In addition, the resident was neglected when the facility failed to administer the residents' antibiotics and inhaler according to physician orders.”

“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. The resident was found with bruising and skin tears on her left arm from an undetermined source. The resident was unable to say what caused the injury, and facility staff were unaware of how the injury occurred. It could not be determined how the injury occurred. The resident was prescribed an inhaler to be administered as needed (PRN). The documentation indicated the resident received the inhaler when needed, and there was no indication the inhaler was administered incorrectly. The resident was prescribed an antibiotic which was not administered until three days after it was ordered. The facility identified the error, administered the full dose of the antibiotic to the resident, and the resident had no negative outcome. An equal opportunity employer.”

Action taken by facility: “Staff re-educated on notifying nurse if new physician orders are received on the weekend and/or when no nurse is at the facility.”

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

Survey completed March 21, 2023: 1 correction order

• Tag 2310: 144G.91 Subd. 4 (a) Appropriate care and services Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure care and services were provided according to acceptable health care and medical, or nursing standards for one of one resident (R1) reviewed for falls and an injury of unknown source.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure care and services were provided according to acceptable health care and medical, or nursing standards for one of one resident (R1) reviewed for falls and an injury of unknown source. Facility nursing staff failed to ensure the source of the falls and injuries were investigated, and interventions were put into place to prevent falls and/or injuries from reoccurrence. [...]”

  Rule cited: “(a) Residents have the right to care and assisted living services that are appropriate based on the resident's needs and according to an up-to-date service plan subject to accepted health care standards.”

Allegation, as written: “The alleged perpetrator (AP) abused a resident when two bruises and a scrape were found on the resident after the AP provided care during an overnight shift.”

“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 insufficient evidence to determine the AP responsible for causing the injuries on the resident.”

Action taken by facility: “The facility investigated the family's concern. The facility no longer employs the AP.”

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

Survey completed September 7, 2022: 1 correction order

• Tag 740: 144G.43 Subd. 4 Transfer of resident records Level 2, isolated scope, scope/level letter D · correction period: Seven (7) Days
  Details

  Summary: MDH found the facility failed to provide necessary medical information during a transfer to the hospital for one of two (R2) residents, who was sent to the hospital via ambulance.

  MDH’s finding, as written: “Based on interview and record review, the facility failed to provide necessary medical information during a transfer to the hospital for one of two (R2) residents, who was sent to the hospital via ambulance. [...]”

  Rule cited: “With the resident's knowledge and consent, if a resident is relocated to another facility or to a nursing home, or if care is transferred to another service provider, the facility must timely convey to the new facility, nursing home, or provider: (1) the [...]”

Allegation, as written: “The facility neglected the resident when plan of care was not followed, and the resident fell sustaining a fractured femur (thigh).”

“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 sustained a fractured femur, the facility had appropriate interventions in place to reduce the risk of falls including frequent checks on the resident.”

Action taken by facility: “The facility made changes to its shift-change process more specific direction and documentation on personal alarm checks.”

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

Survey completed January 8, 2025: no correction orders issued.