The Waters of Highland Park

Survey completed February 3, 2023: 8 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 650: 144G.42 Subd. 8 Employee records Level 2, widespread scope, scope/level letter F · correction period: Twenty-One (21) days
  Details

  Summary: MDH found the licensee failed to ensure employee records included all required content for three of six employees, and executive director (ED)-A (signed performance evaluation), unlicensed personnel (ULP)-F and licensed practical nurse (LPN)-H, (signed performance evaluation) with employee records reviewed.

  MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure employee records included all required content for three of six employees, and executive director (ED)-A (signed performance evaluation), unlicensed personnel (ULP)-F and licensed practical nurse (LPN)-H, (signed performance evaluation) with employee records reviewed. [...]”

  Rule cited: “(a) The facility must maintain current records of each paid employee, each regularly scheduled volunteer providing services, and each individual contractor providing services. [...]”

• 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 ensure that emergency preparedness manual contained the most current contact personnel names and phone numbers.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure that emergency preparedness manual contained the most current contact personnel names and phone numbers. [...]”

  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 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 interconnection of smoke alarms inside the resident apartment unit 224 and the combined apartment unit 415/417.

  MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide interconnection of smoke alarms inside the resident apartment unit 224 and the combined apartment unit 415/417. This has the potential to directly affect the residents in these units receiving assisted living care. [...]”

  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: Twenty-one (21) 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 [...]”

From MDH’s letter: no immediate fines.

Allegation, as written: “The facility neglected the resident when facility staff did not have the resident's pressure relieving air mattress plugged in resulting in pressure sores on the resident's heels.”

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

“In conclusion, the Minnesota Department of Health determined neglect was inconclusive.”

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

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was inconclusive. Due to conflicting accounts provided, there was not a preponderance of evidence to support the resident's air mattress was unplugged and was the direct action that caused the resident's pressure injuries to her heels. When the resident's pressure injuries were identified, they were treated, additional interventions were implemented, and the resident passed away days later at the facility related to her dementia diagnosis. The resident resided in an assisted living memory care unit. The resident's diagnoses included dementia with behavioral disturbance. The resident's service plan included assistance with bathing, dressing, grooming, turning, and repositioning. The resident's assessment indicated the resident had thin fragile skin. The resident was receiving hospice services and had a pressure relieving air mattress. [...]”

Action taken by facility: “The facility collaborated with the hospice team and implemented interventions to prevent worsening of the heel injuries.”

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

Survey completed April 22, 2025: 1 correction order

• Tag 1940: 144G.72 Subd. 3 Individualized treatment or therapy managemen Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure it developed an individual treatment management plan to include all required content for one of one residents (R1)

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure it developed an individual treatment management plan to include all required content for one of one residents (R1) who received an ordered treatment. [...]”

  Rule cited: “For each resident receiving management of ordered or prescribed treatments or therapy services, the assisted living facility must prepare and include in the service plan a written statement of the treatment or therapy services that will be provided to the [...]”

Allegation, as written: “The alleged perpetrator (AP), a facility staff member neglected the resident when the AP administered incorrect medication to the resident.”

“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 medication error occurred, the error was an isolated incident. Upon discovery of the error, the AP immediately notified the facility nurses, emergency medical services, and the resident was sent to the hospital for evaluation. The resident returned to the facility the next day at her baseline health condition.”

Action taken by facility: “The resident was sent to the hospital and AP was retrained on the medication administration. In addition, the facility required staff to no longer park the medication cart in one location. The staff are required to pass medications to residents with the medication cart outside of the resident's apartment.”

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

Survey completed February 10, 2025: no correction orders issued.