Latest Updates on the MDH Assisted Living License Survey Trends

August 30, 2022 by Staff-20220

From the desk of Julie 

It’s hard to believe a year has passed since the Min­neso­ta Depart­ment of Health (MDH) intro­duced new assist­ed liv­ing reg­u­la­tions. To date, there have been 346 sur­vey results post­ed by MDH. The aver­age num­ber of defi­cien­cies per sur­vey is approx­i­mate­ly 14. The top five most com­mon sur­vey defi­cien­cies cit­ed fol­low­ing a state sur­vey were:

1. Tag 0810: 144G.45 Subd. 2 (b)-(f) Fire pro­tec­tion and phys­i­cal envi­ron­ment – Fire Safe­ty and Evac­u­a­tion Plans, Train­ing, and Drills (79% of surveys)
Com­mon prob­lems identified:

  • No evi­dence employ­ees were trained on fire safe­ty and evac­u­a­tion plans upon hire and twice per year
  • No evi­dence of a plan or policy/procedure to make avail­able annu­al fire safe­ty and evac­u­a­tion train­ing for res­i­dents able to assist in their own evacuation
  • Fire/evacuation drills were not planned or documented
  • Fail­ure to ensure fire safe­ty and evac­u­a­tion plans were read­i­ly avail­able to res­i­dents, staff, and visitors
  • Fail­ure to iden­ti­fy res­i­dents who may need addi­tion­al assis­tance for evacuations

2. Tag 0480: 144G.41 Sub­di­vi­sion 1. (13) (i) (B) facil­i­ty is not fol­low­ing the Min­neso­ta Food Code, Ch. 4626; Com­plet­ed by EH – (75% of surveys)
Com­mon prob­lems identified:

  • Inac­cu­rate refrig­er­a­tor tem­per­a­ture or no ther­mome­ter to check the temperature
  • TCS food not date-labeled or stored past date
  • No method to ver­i­fy san­i­tiz­ing solu­tion (test strips) or no solu­tion available
  • No cer­ti­fied food pro­tec­tion man­ag­er is employed or being shared across mul­ti­ple communities
  • No proof staff had been trained in vom­it or fecal mat­ter cleanup pro­ce­dures, and no PPE or cleanup kit made read­i­ly available
  • Improp­er food stor­age – dry goods on the floor, food stored on the floor of the walk-in cool­er, raw foods not on the low­est lev­el of the refrigerator
  • Unkempt kitchen area – rusty shelves, soiled mugs, slime on ice machine, light bulbs burned out, grease on the floor, floor drain miss­ing a cover

3. Tag 0680: 144G.42 Subd. 10 — Dis­as­ter plan­ning and emer­gency pre­pared­ness plan – (60% of surveys)
Com­mon prob­lems identified:

  • No promi­nent sig­nage or post­ings regard­ing the facility’s emer­gency plan at the facil­i­ty entrance, in the hall­ways, in the din­ing area, or the liv­ing areas
  • Emer­gency exit dia­grams were not post­ed on each floor
  • Emer­gency pre­pared­ness staff train­ing (on hire and twice annu­al­ly) was not planned or documented
  • Emer­gency drills were not planned or documented
  • Haz­ard Vul­ner­a­bil­i­ty Analy­sis lack­ing analy­sis of poten­tial vulnerabilities
  • Emer­gency Pre­pared­ness Plan failed to describe the pop­u­la­tion served by the facil­i­ty, the process for coop­er­a­tion with state and local offi­cials, and poli­cies and pro­ce­dures for shel­ter­ing in place

4. Tag 0800: 144G.45 Subd. 2 (a) Phys­i­cal envi­ron­ment – Good Repair and Con­di­tion – (48% of surveys)
Com­mon prob­lems identified:

  • Emer­gency lights or reg­u­lar lights that do not work
  • Doors held open by wedges or that do not latch properly
  • Exit doors blocked
  • Inad­e­quate unob­struct­ed space below sprin­kler heads
  • Loose or miss­ing handrails
  • Floor­ing — cracked or miss­ing tiles, worn or torn carpeting
  • Win­dows in secured unit miss­ing stop­pers to restrict res­i­dent elopement
  • Win­dows in sleep­ing rooms that are too small.

5. Tag 0780: 144G.45 Subd. 2. (a) (1) Fire pro­tec­tion and phys­i­cal envi­ron­ment – Smoke Alarms – (42% of surveys)
Com­mon prob­lems identified:

  • Unplugged smoke alarms
  • Smoke alarms not installed where required
  • Dis­con­nect­ed or dis­abled smoke alarms
  • Smoke alarms with dead bat­ter­ies or expired (more than10 years old)
  • Smoke alarms that were not inter­con­nect­ed with­in a unit
  • Obstruct­ed sprin­kler heads or cov­ered in lint
  • Use of unfused and unap­proved pow­er strips and mul­ti­plug adapters

* Data obtained from Care Providers of Minnesota

What this means for you:
Be pre­pared for when the state arrives at your facil­i­ty. As you can see, most of the top defi­cien­cies are areas new to the assist­ed liv­ing license – food code and envi­ron­men­tal. Make sure your main­te­nance and kitchen staff under­stand the new reg­u­la­tions. Have your main­te­nance team con­duct envi­ron­men­tal inspec­tions to ensure that your facil­i­ty is in good con­di­tion and that the emer­gency plan is up to code. Make sure to have a Cer­ti­fied Food Pro­tec­tion Man­ag­er and that there is always a per­son in charge. Man­agers should con­duct  rou­tine audits of kitchens and staff to ensure prop­er food safety.

For assis­tance with updat­ing your doc­u­ments please vis­it our web­site at


Julie Dietz, RN, PHN
Senior Assist­ed Liv­ing Consultant


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