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February 3, 2023 Debra Shriver 328 5th St SW Suite 5 Willmar, MN 56201 RE: Report No. 202207981 Fourth Avenue Homes Inc. 53rd Avenue License No. 1115695/1068742 Dear Debra Shriver: CORRECTION ORDER An investigation of Fourth Avenue Homes Inc. 53rd Avenue was completed regarding report number 202207981 which alleged violation of Minnesota Statutes, section 626.557, and Minnesota Statutes, Chapter 245D. This maltreatment allegation concerned neglect. The disposition of the investigation report is inconclusive. One violation was noted. VIOLATIONS AND CORRECTION ORDERS The following violation of state and (or) federal laws and rules was observed. Corrective action for the violation is required by Minnesota Statutes, section 245A.06, and is hereby ordered by the Commissioner of Human Services. Failure to correct the violations within the prescribed amount of time may result in fines and/or action against your license, as provided for in Minnesota Statutes, sections 245A.06 and 245A.07. Citation: Minnesota Statutes, section 245D.05, subdivision 2, paragraph (a) and (b) Violation: For one consumer’s (C’s) record that was reviewed, the license holder did not provide medication administration as required. The license holder was responsible for administering the C’s medication in accordance with the C’s coordinated service and support plan addendum. The license holder failed to implement medication administration procedures to ensure the C took the medications as prescribed. From September 22 to September 25, 2022, the C was not given his/her prescribed medication. Corrective Action Ordered: Immediately, and on an ongoing basis, you must maintain compliance as required in this subdivision. If you have any questions regarding the investigation, contact me immediately. If you have any questions regarding compliance with this Correction Order or applicable rules, contact your licensor, Lindsay Norris, at 651-431-5752. If you believe any of the citations are in error, you may ask the Commissioner of Human Services to reconsider the parts of the correction order that you believe to be in error. If you choose to exercise this right, your request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this letter. Your request for reconsideration must be sent to: Commissioner Minnesota Department of Human Services c/o Licensing Division PO Box 64242 St. Paul, MN 55164-0242 You must include any and all information, documentation, or other evidence you have to support your request for reconsideration. Please note that a request for reconsideration does not stay any provisions of the correction order. Sincerely,
Scott Broady, Investigator Office of Inspector General Licensing Division scott.broady@state.mn.us 651-431-6557 Enclosure
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