Norbella Senior Living Prior L.
Norbella Senior Living Prior L is Grade C, ranked in the top 49% of Minnesota memory care with 1 MDH citation on record; last inspected Jan 2026.
A medium home, reviewed on public record.
Ranked against 187 Minnesota facilities.
ALF memory care · 36-month window. Higher percentile = better. Source: Minnesota Dept. of Health · Health Regulation Division.
FACILITY WATCH · BETA
Norbella Senior Living Prior L has 1 citation on record. Know the moment anything changes.
New findings, complaint investigations, or status changes — emailed to you free.
Citation history, plotted month by month.
1 deficiencie on record. Each bar is a month with a citation.
Finding distribution
1 total · 36 monthsScope × Severity (CMS A–L)
Questions to ask before you visit.
A short pre-tour checklist tailored to Norbella Senior Living Prior L's record and state requirements.
The most recent inspection on January 7, 2026, resulted in zero deficiencies — can you walk us through the documentation you maintain to demonstrate ongoing compliance with Minnesota Statutes chapter 144G dementia care requirements, and how often do you conduct internal audits?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
One complaint was filed with the Minnesota Department of Health during the inspection period on file — was that complaint substantiated, and what corrective measures did the facility implement in response?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
This facility holds an Assisted Living Facility with Dementia Care license under Minnesota law — can you provide a copy of your written dementia care program and explain how staff competency in dementia care is documented and verified across all shifts?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
Every MDH visit, verbatim.
3 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.
2026-01-07Annual Compliance VisitNo findings
Plain-language summary
A follow-up survey on April 8, 2026 found that the facility had not corrected violations from a January 7, 2026 inspection, resulting in correction orders for background studies, medication documentation, treatment documentation, appropriate care and services, and resident records; the facility was assessed $1,500 in fines for two of these violations. The facility must document actions taken to comply with these orders and has the right to request reconsideration or a hearing within 15 days of receiving this notice.
Full inspector notes
correction orders issued pursuant to the January 7, 2026 survey. In accordance with Minn. Stat. § 144G.31 Subd. 4 (a), state correction orders issued pursuant to the last survey, completed on January 7, 2026, found not corrected at the time of the April 8, 2026, follow-up survey and/ or subject to penalty assessment are as follows: 1290-Background Studies Required- 144g.60 Subdivision 1 - $500.00 1760-Documentation Of Administration Of Medication- 144g.71 Subd. 8 - $1,000.00 1960-Documentation Of Administration Of Treatments- 144g.72 Subd. 5 2320-Appropriate Care And Services-144g.91 Subd. 4 (b) The details of the violations noted at the time of this follow-up survey completed on April 8, 2026 (listed above), are on the attached State Form. Brackets around the ID Prefix Tag in the left hand column, e.g., {2 ----} will identify the uncorrected tags. The refor e, in accor danc e wit h Minn. Sta t. §§ 144G.01 to 144G.999 9, the total amount you are assessed is $1,500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal . Also, at the time of this follow-up survey completed on April 8, 2026, we identified the following violation(s): 0700-Resident Record-144g.43 Subdivision 1 The details of the violation(s) noted at the time of this follow-up survey are delineated on the attached State Form. Only the ID Prefix Tag in the left hand column without brackets will identify these state correction orders. It is not necessary to develop a plan of correction. An equal opportunity employer. Letter ID: 8GKP Revised 04/14/2023 Norbella Senior Living Prior Lake April 21, 2026 Page 2 DOCUMENTATIO ONF ACTION TO COMPLY In accorda nce with Min n. Stat. § 144G.30, Sub d. 5(c), th e lic ens ee mus t docum ent ac tions taken t o comply with the correction orders outlined on the state form; however, plans of correction are not required to be submitted for approval. IMPOSITION OF FINES In accordance with Minn. Stat. § 144G.31, Subd. 4, fines and enforcement actions may be imposed based on the level and scope of the violations and may be imposed immediately with no opportunity to correct the violation first as follows: Level 1: no fines or enforcement; Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G.20; Level 3: a fine of $1,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Level 4: a fine of $3,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20; Level 5: a fine of $5,000 per violation, in addition to any enforcement mechanism authorized in § 144G.20. CORRECTIO NORDER RECONSIDERATIO PNROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order( s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. To submit a reconsideration request, please visit: https: / / forms. web. health. state. mn.us/ form/ HRDAppealsForm REQUESTIN GA HEARING Alternatively, in accordance with Minn. Stat. § 144G.31, Subd. 5(d), an assisted living provider that has been assessed a fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuant to Minn. Stat. § 144G.20, Subd. 14 and Subd. 18, a request for a hearing must be in writing and received by the Department of Health within 15 business days of the correction order receipt date. The request must contain a brief and plain statement describing each matter or issue contested and any new information you believe constitutes a defense or mitigating factor. To submit a hearing request, please visit: https: / / forms. web. health. state. mn. us/ form/ HRDAppealsForm To appe al fi nes via re cons iderat ion , pl ease follow the procedu r e outl ined abo ve. Plea se no te tha t you may re que st a rec onside rati on or a hearing, bu t not bot h. If you wish to cont est ta gs with out fine s in a reconsideration and tags with the fines at a hearing, please submit two separate appeals forms at Norbella Senior Living Prior Lake April 21, 2026 Page 3 the website listed above. We urge you to review these orders carefully. If you have questions, please contact Jodi Johnson at You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and/ or state form with your organization’s Governing Body. Sincerely, Jodi Johnson, Supervisor State Evaluation Team Email: Renee. L.Anderson@state. mn.us Telephone: 651-201-5871 Fax: 1-866-890-9290 HHH PRINTED: 04/ 21/ 2026 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/ SUPPLIER/ CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 37315 04/ 08/ 2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4285 FOUNTAIN HILL DRIVE NE NORBELLA SENIOR LIVING PRIOR L PRIOR LAKE, MN 55372 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER' S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS- REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) {0 000} Initial Comments {0 000} ******ATTENTION****** Minnesota Department of Health is documenting the State Correction Orders ASSISTED LIVING PROVIDER FOLLOW UP using federal software. Tag numbers have SURVEY WITH RE- ISSUE OF ORDERS been assigned to Minnesota State Statutes for Assisted Living Facilities. The INITIAL COMMENTS assigned tag number appears in the SL37315016- 1 far-left column entitled "ID Prefix Tag. " The state Statute number and the On April 8, 2026, the Minnesota Department of corresponding text of the state Statute out Health conducted a deck follow-up survey for the of compliance is listed in the "Summary above provider to follow-up on orders issued Statement of Deficiencies" column. This pursuant to a survey completed on January 7, column also includes the findings which 2026. As a result of the follow-up survey, the are in violation of the state requirement following orders were issued and/ or reissued: after the statement, "This Minnesota 0700, 1290, 1760, 1960, 2320. requirement is not met as evidenced by." Following the evaluators' findings is the Time Period for Correction. PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH STATES, "PROVIDER' S PLAN OF CORRECTION. " THIS APPLIES TO FEDERAL DEFICIENCIES ONLY. THIS WILL APPEAR ON EACH PAGE. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G. 31 SUBDIVISION 1-3. 0 700 144G. 43 Subdivision 1 Resident record 0 700 SS= E (b) Resident records, whether written or LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 QILZ12 If continuation sheet 1 of 17 PRINTED: 04/ 21/ 2026 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/ SUPPLIER/ CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 37315 04/ 08/ 2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4285 FOUNTAIN HILL DRIVE NE NORBELLA SENIOR LIVING PRIOR L PRIOR LAKE, MN 55372 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER' S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS- REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 700 Continued From page 1 0 700 electronic, must be protected against loss, tampering, or unauthorized disclosure in compliance with chapter 13 and other applicable relevant federal and state laws. The facility shall establish and implement written procedures to control use, storage, and security of resident records and establish criteria for release of resident information. This MN Requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee failed to ensure resident records were protected against unauthorized disclosure of electronic records.
2025-02-18Complaint Investigation1 · Substantiated Finding
Plain-language summary
A complaint investigation substantiated that the facility neglected a resident by failing to call 911 promptly when staff found him unresponsive and in medical distress; instead, staff contacted the on-call nurse and attempted to reach family first, delaying emergency care by over an hour despite the resident's POLST indicating he wanted full resuscitation in a medical emergency. The resident was transported to the hospital where he died from septic shock and aspiration pneumonia. The investigation found facility staff had been educated to contact 911 if a resident was found unconscious, but facility policy directed staff to contact the on-call nurse first, which contributed to the delay in emergency treatment.
“MDH substantiated maltreatment or licensing violation finding”
Full inspector notes
Finding: Substantiated, facility responsibility Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The facility neglected a resident when they failed to appropriately respond and provide necessary medical care when the resident was found unresponsive and in medical distress. The resident experienced a medical emergency, but the facility waited an hour before calling 911 which delayed the resident receiving necessary emergency medical care. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. Although facility staff were educated to contact the emergency number 911 if they found a resident unconscious, instead staff contacted leadership and an on-call nurse, and attempted to contact the resident’s family prior to contacting 911. That resulted in a delay of treatment for the resident of over one hour from the time when staff found the resident unresponsive until 911 was contacted. The resident was transported to the hospital where he later died from septic shock (life threatening condition) and aspiration pneumonia (accidentally inhaling food, liquid, or vomit into the lungs). The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s family members, law enforcement, and the resident’s primary care provider. The investigation included review of the resident’s facility record, in-house provider’s record, police body cam footage and transcription, the resident’s death record, hospital record, facility internal investigation, personnel files, staff schedules, law enforcement report, ambulance run report, and related facility policy and procedures. Also, the investigator observed direct cares during the onsite investigation. The resident resided in an assisted living memory care unit. The resident’s diagnoses included emphysema (chronic lung disease), dementia, lymphoblastic lymphoma (aggressive cancer that affects the bone marrow), and diabetes with diabetic neuropathy (numbness and pain from nerve damage.) The resident’s service plan included assistance with personal cares, orientation for confusion, toileting, medication management, transfers, walking, insulin administration, and blood sugar checks four times per day. The resident was oriented to person and time and was unable to use a call pendant due to lacking the physical or cognitive capability. The resident had difficulty with communication but was able to make his needs known. The resident’s Physician Orders for Life Sustaining Treatment (POLST) indicated the resident wanted full resuscitation, and other treatments in the event of a medical emergency. A progress note indicated one early evening at 4:58 p.m., the facility nurse (who was the on-call nurse) received a call from unlicensed staff indicating the resident appeared lethargic (weak.) Vital signs indicated the resident’s heart rate was fast (tachycardic) at 124 beats per minute (normal 60-100) with a low blood sugar of 84 mg/dL (considered a low blood sugar reading for the resident). The on-call nurse advised staff to monitor the resident and update her of any changes in the resident’s status. Approximately 20 minutes later, staff contacted the on-call nurse to report the resident vomited and appeared to be feeling better. The on-call nurse directed staff to continue to monitor the resident. About 10 hours later, unlicensed staff contacted the on-call nurse to report the resident was cold, clammy, had vomited, with a change noticed in his breathing. The resident’s pulse was elevated at 102 and his blood sugar was 452 mg/dL (elevated.) The nurse advised staff to contact the resident’s family to confirm their preference of keeping the resident at the facility or being evaluated at a hospital. The nurse documented, “Unable to get ahold of family.” After staff’s few attempts to reach the family member, unlicensed staff called the on-call nurse again who directed staff to call 911. The documentation failed to indicate whether unlicensed staff reported to the on-call nurse they found the resident unresponsive. Review of the resident’s ambulance run report indicated early morning about one hour and 15 minutes after finding the resident unresponsive, emergency medical services were dispatched to the facility after receiving a call from unlicensed staff regarding the resident’s breathing problem. The report indicated unlicensed staff reported the resident was unresponsive, with cyanosis (bluish/purple skin due to low oxygen levels) and agonal breathing (gasping breathing signaling near death) for approximately one hour before 911 was called. Vital signs obtained from the emergency medical personnel indicated the resident’s oxygen saturation (level of oxygen in the blood) was at 54% on room air (normal readings 94%-100%). During the transfer to a hospital, the resident required supplemental oxygen and breathing treatments. Review of the police body cam footage and transcription indicated three facility staff stated two hours before finding the resident unresponsive, they opened the resident’s door to look at the resident but did not enter his room because he was “sleeping.” Staff stated two hours later when checking the resident, the resident had vomited and was gasping in distress. On the police body cam, the three unlicensed staff stated it was a facility policy to contact the on-call nurse first before contacting 911. The resident’s hospital record indicated the resident presented to the emergency department unresponsive, in respiratory distress, and high fever (102.2 Fahrenheit (F)). The resident was diagnosed with aspiration pneumonia and sepsis (rapid breathing, fast heart rate, fever, low blood pressure, and chills). Despite hospital staff’s attempts at treatment the resident was placed on comfort care and died hours later. The resident’s death certificate listed septic shock as the resident’s immediate cause of death. Review of employee files for facility staff indicated all staff were trained on when to call 911 and facility policies related to resident medical emergencies. A facility document titled Medical Emergencies, indicated if a resident was found unconscious, facility staff were to call 911 right away before calling the on-call nurse. The facility internal investigation indicated during the evening meal, resident appeared lethargic, so unlicensed staff called and updated the facility nurse on the resident’s condition. When interviewed, unlicensed staff stated the nurse thought the resident’s vitals seemed “okay” but said the nurse told them to keep an “eye” on the resident. The unlicensed staff member stated around 3:00 a.m., there were three unlicensed staff in the resident’s room trying to clean the resident after the resident vomited. The unlicensed staff member stated the resident had vomit coming from his mouth, down his chest, body, and “all over” his bed sheets. The unlicensed staff member observed the resident’s breathing was shallow and his hands were blue. After finding the resident in distress, staff immediately called facility leadership because they did not know who the on-call nurse was that night. Facility leadership instructed staff to obtain the resident’s vitals then call the on-call nurse. The on-call nurse documented the resident’s vitals were “stable, other than the resident’s pulse of 102 and blood sugar reading of 452 mg/dL.” The on-call nurse instructed staff to call the resident’s family member first, “to be sure they wanted to send the resident out.” After three unsuccessful attempts to contact the resident’s family member, unlicensed staff called the on-call nurse back who directed staff to call 911. During an interview, an unlicensed staff member stated at 3:00 a.m. they observed the resident was unresponsive with mottling (blotching skin) and his feet were cold. The unlicensed staff member contacted the on-call nurse who told her to call the resident’s family member. After not being able to contact the resident’s family, the unlicensed staff stated they called the on-call nurse back telling the on-call nurse “we need to call 911.” The unlicensed staff stated they called the on-call nurse back who agreed the resident should be evaluated at a hospital. During an interview, leadership stated they received a call from unlicensed staff between 3:00 a.m. and 3:15 a.m. reporting the resident vomited and appeared to not be well. Leadership stated unlicensed staff did not know who the on-call nurse was, so leadership advised staff to call the facility nurse who was the on-call nurse to update the nurse on the resident’s condition. When interviewed, the nurse stated she thought the resident had an upset stomach based on the information provided to her from unlicensed staff. The nurse stated she did tell staff to monitor the resident and update her regarding any change in his status.
2023-06-12Annual Compliance VisitNo findings
Plain-language summary
A routine inspection of this assisted living facility with dementia care was completed on June 14, 2023, which resulted in one correction order for a violation of the infection control program statute. The facility was assessed a $500 fine for this Level 2 violation and must document the actions taken to correct the deficiency.
Full inspector notes
CORRECTION ORDERS The enclosed State Form documents the state correction orders. The MDH documents state licensing correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Assisted Living Facilities. The assigned tag number appears in the far left column entitled "ID Prefix Tag." The state statute number and the corresponding text of the state statute out of compliance are listed in the "Summary Statement of Deficiencies" column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requirement is not met as evidenced by . . ." IMPOSITION OF FINES In accordance with Minn. Stat. § 144G.31, Subd. 4, fines and enforcement actions may be imposed based on the level and scope of the violations and may be imposed immediately with no opportunity to correct the violation first as follows: Level 1: no fines or enforcement. Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G.20 for widespread violations; Level 3: a fine of $3,000 per violation per incident, in addition to any enforcement mechanism authorized in § 144G.20. Level 4: a fine of $5,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20. In accordance with Minn. Stat. § 144G.31, Subd. 4 (a)(5), the MDH may impose fine amounts of either $1,000 or $5,000 to licensees who are found to be responsible for maltreatment. The MDH may impose a fine of $1,000 for each substantiated maltreatment violation that consists of abuse, neglect, or financial exploitation according to Minn. Stat. § 626.5572, Subds. 2, 9, 17. The MDH An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Norbella Senior Living Prior Lake July 10, 2023 Page 2 also may impose a fine of $5,000 for each substantiated maltreatment violation consisting of sexual assault, death, or abuse resulting in serious injury. In accordance with Minn. Stat. § 144G.31, Subd. 4 (b), when a fine is assessed against a facility for substantiated maltreatment, the commissioner shall not also impose an immediate fine under this chapter for the same circumstance. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: St ‐ 0 ‐ 0510 ‐ 144g.41 Subd. 3 ‐ Infection Control Program ‐ $500.00 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the total amount you are assessed is $500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. DOCUMENTATION OF ACTION TO COMPLY In accordance with Minn. Stat. § 144G.30, Subd. 5(c), the licensee must document actions taken to comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: Identify how the area(s) of noncompliance was corrected related to the resident(s)/employee(s) identified in the correction order. Identify how the area(s) of noncompliance was corrected for all of the provider’s resident(s)/employees that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). CORRECTION ORDER RECONSIDERATION PROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order(s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by the MDH within 15 calendar days of the correction order receipt date. A state correction order under Minn. Stat. § 144G.91, Subd. 8, Free from Maltreatment is associated with a maltreatment determination by the Office of Health Facility Complaints. If maltreatment is substantiated, you will receive a separate letter with the reconsideration process under Minn. Stat. § 626.557. Please email reconsideration requests to: Health.HRD.Appeals@state.mn.us. Please attach this letter as part of your reconsideration request. Please clearly indicate which tag(s) you are contesting and submit information supporting your position(s). Norbella Senior Living Prior Lake July 10, 2023 Page 3 Please address your cover letter for reconsideration requests to: Reconsideration Unit 85 East Seventh Place St. Paul, MN 55164‐0970 REQUESTING A HEARING Alternatively, in accordance with Minn. Stat. § 144G.31, Subd. 5(d), an assisted living provider that has been assessed a fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuant to Minn. Stat. § 144G.20, Subd. 14 and Subd. 18, a request for a hearing must be in writing and received by the MDH within 15 business days of the correction order receipt date. The request must contain a brief and plain statement describing each matter or issue contested and any new information you believe constitutes a defense or mitigating factor. Requests for hearing may be emailed to: Health.HRD.Appeals@state.mn.us. To appeal fines via reconsideration, please follow the procedure outlined above. Please note that you may request a reconsideration or a hearing, but not both. You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Jessica Chenze, Supervisor State Evaluation Team Email: jessie.chenze@state.mn.us Telephone: 218‐332‐5175 Fax: 651‐281‐9796 JMD PRINTED: 07/10/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ 37315 B. WING _____________________________ 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4285 FOUNTAIN HILL DRIVE NE NORBELLA SENIOR LIVING PRIOR L PRIOR LAKE, MN 55372 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 0 000 Initial Comments 0 000 ******ATTENTION****** Minnesota Department of Health is documenting the State Correction Orders ASSISTED LIVING PROVIDER LICENSING using federal software. Tag numbers have CORRECTION ORDER(S) been assigned to Minnesota State Statutes for Assisted Living License In accordance with Minnesota Statutes, section Providers. The assigned tag number 144G.08 to 144G.95, these correction orders are appears in the far left column entitled "ID issued pursuant to a survey. Prefix Tag." The state Statute number and the corresponding text of the state Statute Determination of whether violations are corrected out of compliance is listed in the requires compliance with all requirements "Summary Statement of Deficiencies" provided at the Statute number indicated below. column. This column also includes the When Minnesota Statute contains several items, findings which are in violation of the state failure to comply with any of the items will be requirement after the statement, "This considered lack of compliance. Minnesota requirement is not met as evidenced by." Following the surveyors' INITIAL COMMENTS: findings is the Time Period for Correction. SL37315015 PLEASE DISREGARD THE HEADING OF On June 12, 2023, through June 14, 2023, the THE FOURTH COLUMN WHICH survey at the above provider, and the following CORRECTION." THIS APPLIES TO correction orders are issued. At the time of the FEDERAL DEFICIENCIES ONLY. THIS survey, there were 29 active residents; all WILL APPEAR ON EACH PAGE. receiving services under the Assisted Living with Dementia Care license. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. The letter in the left column is used for tracking purposes and reflects the scope and level issued pursuant to 144G.31 subd. 1, 2, and 3. 0 510 144G.41 Subd. 3 Infection control program 0 510 SS=F (a) All assisted living facilities must establish and maintain an infection control program that LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 TP5C11 If continuation sheet 1 of 49 PRINTED: 07/10/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ 37315 B.
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