The Sanctuary at West St Paul

Survey completed February 16, 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.

  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 780: 144G.45 Subd. 2 (a) (1) Fire protection and physical environment Level 2, pattern scope, scope/level letter E · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to provide working smoke alarms inside resident apartment units 203 and 426.

  MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide working smoke alarms inside resident apartment units 203 and 426. This has the potential to directly affect the resident in units 203 and 426. [...]”

  Rule cited: “(a) Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and: (1) for dwellings or sleeping units, as defined in the State Fire Code: (i) provide smoke alarms in each room used for sleeping purposes; (ii) [...]”

• Tag 800: 144G.45 Subd. 2 (a) (4) Fire protection and physical environment Level 2, widespread scope, scope/level letter F · correction period: Fourteen (14) days
  Details

  Summary: MDH found the licensee failed to maintain the physical environment of the facility in a continuous state of good repair and operation.

  MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the physical environment of the facility in a continuous state of good repair and operation. This has the potential to directly affect the health, safety, and well-being of all residents and staff. [...]”

  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 [...]”

• Tag 810: 144G.45 Subd. 2 (b)-(f) Fire protection and physical environment Level 2, widespread scope, scope/level letter F · correction period: Twenty (21) days
  Details

  Summary: MDH found the licensee failed to provide the minimum required employee training on fire safety and evacuation.

  MDH’s finding, as written: “Based on observation, record review, and interview, the licensee failed to provide the minimum required employee training on fire safety and evacuation. This has the potential to directly affect the safety of all residents receiving services, staff, and visitors. [...]”

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

• Tag 1880: 144G.71 Subd. 19 Storage of medications Level 2, widespread scope, scope/level letter F · correction period: Seven (7)
  Details

  Summary: MDH found the licensee failed to ensure refrigerated medications were maintained at manufactured recommended temperatures by failing to monitor and document medication refrigerator temperatures located in one of one refrigerator where resident medications were stored.

  MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure refrigerated medications were maintained at manufactured recommended temperatures by failing to monitor and document medication refrigerator temperatures located in one of one refrigerator where resident medications were stored. [...]”

  Rule cited: “An assisted living facility must store all prescription medications in securely locked and substantially constructed compartments according to the manufacturer's directions and permit only authorized personnel to have access.”

• 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 labeled correctly for one of one hundred thirty-nine residents (R8).

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were labeled correctly for one of one hundred thirty-nine residents (R8). 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 an isolated scope (when one or a limited number of residents are [...]”

  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 develop a safety risk assessment plan to identify hazard vulnerabilities and mitigations on and around the property to protect memory care residents from harm.

  MDH’s finding, as written: “Based on the document review and interview, the licensee failed to develop a safety risk assessment plan to identify hazard vulnerabilities and mitigations on and around the property to protect memory care residents from harm. This has the potential to directly affect staff, visitors, and all memory care residents receiving assisted living services. [...]”

  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 the resident when she fell out of bed and became entangled in her wheelchair overnight. At the hospital, the resident was diagnosed with rhabdomyolysis, a potentially life-threatening syndrome involving the rapid breakdown of damaged skeletal muscle, releasing toxic intracellular contents into the bloodstream. The resident was treated and moved to a transitional care unit (TCU) for rehabilitation.”

“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's care plan was followed at the time of the incident. When staff became aware of the fall, the resident was assessed and sent to the hospital for further evaluation. The resident was treated and returned to her baseline health status.”

Action taken by facility: “The facility responded to the resident's fall per protocol and updated her service plan to include an overnight safety check.”

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

Survey completed May 5, 2026: no correction orders issued.

Allegation, as written: “The Alleged Perpetrator (AP) financially exploited the resident when she convinced the resident to sign the resident's automobile over to her.”

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

Summary: MDH looked into an allegation and found: financial exploitation not substantiated.

MDH’s conclusion, as written: “The Minnesota Department of Health determined financial exploitation was not substantiated. The AP violated professional boundaries when she arranged a financial transaction with the resident. However, the AP paid what the resident and her family considered to be a fair price for the car. The resident did not incur a financial loss, and the incident did not meet the definition of financial exploitation.”

Action taken by facility: “The facility provided refresher training to staff regarding appropriate boundaries. The AP's employment was terminated.”

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

Survey completed June 3, 2025: no correction orders issued.