A Daughter's Love

Summary: MDH found the licensee failed to post the required information related to the grievance procedure.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to post the required information related to the grievance procedure. This had the potential to affect all current residents, staff, and visitors. [...]”

Rule cited: “All facilities must post in a conspicuous place information about the facilities' grievance procedure, and the name, telephone number, and email contact information for the individuals who are responsible for handling resident grievances. [...]”

Summary: MDH found the licensee failed to engage in and maintain documentation of a quality management activity appropriate to the size of the facility and relevant to the type of services provided.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to engage in and maintain documentation of a quality management activity appropriate to the size of the facility and relevant to the type of services provided. This had the potential to affect all 15 residents receiving assisted living services. [...]”

Rule cited: “The facility shall engage in quality management appropriate to the size of the facility and relevant to the type of services provided. [...]”

Summary: MDH found the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment for three of three residents (R1, R4, R8).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment for three of three residents (R1, R4, R8). [...]”

Rule cited: “(a) The assisted living facility must comply with the requirements for the reporting of maltreatment of vulnerable adults in section 626.557. [...]”

Summary: MDH found the licensee failed to post required content in the commons area to include posting the 911 emergency number, and the reporting number for the Minnesota Adult Abuse Reporting Center (MAARC) to report suspected maltreatment of a vulnerable adult under section 626.557.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to post required content in the commons area to include posting the 911 emergency number, and the reporting number for the Minnesota Adult Abuse Reporting Center (MAARC) to report suspected maltreatment of a vulnerable adult under section 626.557. This had the potential to affect all 15 residents, staff and visitors. [...]”

Rule cited: “The facility shall support protection and safety through access to the state's systems for reporting suspected criminal activity and suspected vulnerable adult maltreatment by: (1) posting the 911 emergency number in common areas and near telephones provided [...]”

Summary: MDH found the licensee failed to ensure the provider established and maintained a tuberculosis (TB) prevention program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC), which included completion of a facility risk assessment.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the provider established and maintained a tuberculosis (TB) prevention program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC), which included completion of a facility risk assessment. [...]”

Rule cited: “(a) The facility must establish and maintain a comprehensive tuberculosis infection control program according to the most current tuberculosis infection control guidelines issued by the United States Centers for Disease Control and Prevention (CDC), Division [...]”

Summary: MDH found the licensee failed to ensure that the appropriate records for nine of nine residents (R1, R2, R4, R5, R6, R7, R8, R9, R10), were readily available for timely access to employees, vendors, and the commissioner authorized to access the records.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure that the appropriate records for nine of nine residents (R1, R2, R4, R5, R6, R7, R8, R9, R10), were readily available for timely access to employees, vendors, and the commissioner authorized to access the records. [...]”

Rule cited: “The facility must ensure that the appropriate records are readily available to employees and contractors authorized to access the records. Resident records must be maintained in a manner that allows for timely access, printing, or transmission of the records. [...]”

Summary: MDH found the licensee failed to include documentation of incidents involving the resident and actions taken in response to the needs of the resident, including reporting to the appropriate supervisor or health care professional for four of five residents (R1, R8, R13, R14).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to include documentation of incidents involving the resident and actions taken in response to the needs of the resident, including reporting to the appropriate supervisor or health care professional for four of five residents (R1, R8, R13, R14). [...]”

Rule cited: “Contents of a resident record include the following for each resident: (1) identifying information, including the resident's name, date of birth, address, and telephone number; (2) the name, address, and telephone number of the resident's emergency contact, [...]”

Summary: MDH found the licensee failed to comply with Minnesota State Fire Code, under Minnesota Rules Chapter 7511.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to comply with Minnesota State Fire Code, under Minnesota Rules Chapter 7511. This had the potential to directly affect all residents, staff, and visitors. [...]”

Rule cited: “Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and:”

Summary: MDH found the licensee failed to provide smoke alarms that complied with fire protection requirements.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide smoke alarms that complied with fire protection requirements. This had the potential to directly affect more than a limited number of residents, staff, and visitors. [...]”

Rule cited: “for dwellings or sleeping units, as defined in the State Fire Code: (i) provide smoke alarms in each room used for sleeping purposes; (ii) provide smoke alarms outside each separate sleeping area in the immediate vicinity of bedrooms; (iii) provide smoke [...]”

Summary: MDH found the licensee failed to install and maintain portable fire extinguishers as required by statute.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to install and maintain portable fire extinguishers as required by statute. This deficient condition had the potential to affect all residents, staff, and visitors. [...]”

Rule cited: “(2) install and maintain portable fire extinguishers in accordance with the State Fire Code; (3) install portable fire extinguishers having a minimum 2-A:10-B:C rating within Group R-3 occupancies, as defined by the State Fire Code, located so that the travel [...]”

Summary: MDH found the licensee failed to provide the physical environment in a continuous state of good repair and operation with regard to the health, safety, and well-being of the residents.

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

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 [...]”

Summary: MDH found the licensee failed to develop the fire safety and evacuation plan with required content, make the plan readily available, and provide required training and drills.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop the fire safety and evacuation plan with required content, make the plan readily available, and provide required training and drills. This had the potential to directly affect all residents, staff, and visitors. [...]”

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

Summary: MDH found the licensee failed to submit a Minnesota Department of Health Engineering Services plan review application and obtain a local permit for construction of a building addition.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to submit a Minnesota Department of Health Engineering Services plan review application and obtain a local permit for construction of a building addition. This had the potential to directly affect all residents, staff, and visitors. [...]”

Rule cited: “Assisted living facilities shall comply with all applicable state and local governing laws, regulations, standards, ordinances, and codes for fire safety, building, and zoning requirements, except a facility with a licensed resident capacity of six or fewer [...]”

Summary: MDH found the licensee failed to develop and execute a written contract, with the required content prior to providing assisted living services for two of three residents (R1, R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop and execute a written contract, with the required content prior to providing assisted living services for two of three residents (R1, R2). [...]”

Rule cited: “(a) An assisted living facility may not offer or provide housing or assisted living services to any individual unless it has executed a written contract with the resident. [...]”

Summary: MDH found the licensee failed to ensure the assisted living contract did not include language waiving the facility's liability for health, safety, or personal property of a resident for one of one resident (R4).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the assisted living contract did not include language waiving the facility's liability for health, safety, or personal property of a resident for one of one resident (R4). [...]”

Rule cited: “The contract must not include a waiver of facility liability for the health and safety or personal property of a resident. [...]”

Summary: MDH found the licensee failed to provide written notice with required content to the resident, legal representative, and designated representative for one of one resident (R4) with an emergency relocation.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to provide written notice with required content to the resident, legal representative, and designated representative for one of one resident (R4) with an emergency relocation. [...]”

Rule cited: “(a) A facility may remove a resident from the facility in an emergency if necessary due to a resident's urgent medical needs or an imminent risk the resident poses to the health or safety of another facility resident or facility staff member. [...]”

Summary: MDH found the licensee failed to ensure current employee records contained all the required content to include a current background study clearance letter for two of nine employees (unlicensed personnel (ULP)-H, ULP-I).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure current employee records contained all the required content to include a current background study clearance letter for two of nine employees (unlicensed personnel (ULP)-H, ULP-I). This had the potential to affect all residents living within the facility. This resulted in an immediate correction order identified on February 5, 2025. [...]”

Rule cited: “(a) Employees, contractors, and regularly scheduled volunteers of the facility are subject to the background study required by section 144.057 and may be disqualified under chapter 245C. [...]”

Summary: MDH found the licensee failed to ensure a registered nurse (RN) provided training or the training was provided by another instructor in conjunction with a RN, and competency evaluations were completed by the RN for unlicensed personnel (ULP) providing assisted living services for two of two employees (ULP-F, ULP-G).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a registered nurse (RN) provided training or the training was provided by another instructor in conjunction with a RN, and competency evaluations were completed by the RN for unlicensed personnel (ULP) providing assisted living services for two of two employees (ULP-F, ULP-G). [...]”

Rule cited: “Instructors and competency evaluators must meet the following requirements: (1) training and competency evaluations of unlicensed personnel who only provide assisted living services specified in section 144G.08, subdivision 9, clauses (1) to (5), must be [...]”

Summary: MDH found the licensee failed to ensure training and competency was completed for two of two unlicensed personnel ((ULP)-F, ULP-G) to include all required content.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure training and competency was completed for two of two unlicensed personnel ((ULP)-F, ULP-G) to include all required content. [...]”

Rule cited: “(a) Training and competency evaluations for all unlicensed personnel must include the following: (1) documentation requirements for all services provided; (2) reports of changes in the resident's condition to the supervisor designated by the facility; (3) [...]”

Summary: MDH found the licensee failed to ensure training and competency was completed for two of two unlicensed personnel ((ULP)-F, ULP-G) to include all required content.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure training and competency was completed for two of two unlicensed personnel ((ULP)-F, ULP-G) to include all required content. [...]”

Rule cited: “(b) In addition to paragraph (a), training and competency evaluation for unlicensed personnel providing assisted living services must include: (1) observing, reporting, and documenting resident status; (2) basic knowledge of body functioning and changes in [...]”

Summary: MDH found the licensee failed to provide staff orientation to assisted living licensing requirements and regulations for one of one employee (unlicensed personnel (ULP)-F).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to provide staff orientation to assisted living licensing requirements and regulations for one of one employee (unlicensed personnel (ULP)-F). [...]”

Rule cited: “(a) All staff providing and supervising direct services must complete an orientation to assisted living facility licensing requirements and regulations before providing assisted living services to residents. [...]”

Summary: MDH found the licensee failed to ensure an employee received all the required annual training content for each 12 months of employment for one of one employee (clinical nurse supervisor (CNS)-D).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure an employee received all the required annual training content for each 12 months of employment for one of one employee (clinical nurse supervisor (CNS)-D). In addition, the licensee failed to ensure at least eight hours of annual training for each 12 months of employment for one of one employee (CNS-D). [...]”

Rule cited: “(a) All staff that perform direct services must complete at least eight hours of annual training for each 12 months of employment. [...]”

Summary: MDH found the licensee failed to ensure one of one employee (unlicensed personnel (ULP-F)) received the required amount of dementia care training in the required time frame.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one of one employee (unlicensed personnel (ULP-F)) received the required amount of dementia care training in the required time frame. In addition, the licensee failed to ensure one of one employee (clinical nurse supervisor (CNS)-D) received at least two hours of dementia care training for each 12 months of employment. [...]”

Rule cited: “(a) All assisted living facilities must meet the following training requirements: (1) supervisors of direct-care staff must have at least eight hours of initial training on topics specified under paragraph (b) within 120 working hours of the employment start [...]”

MDH’s finding, as written: “This correction order was modified on February 18, 2025, to add additional information regarding R2, R4, and R5. In addition, the scope was changed to widespread (I). Based on observation, interview and record review, the licensee failed to ensure the registered nurse (RN) completed a comprehensive reassessment with a change in condition and failed to ensure 90-day comprehensive assessments did not exceed 90 days for four of four residents (R1, R2, R4, R5). [...]”

Rule cited: “(c) Resident reassessment and monitoring must be conducted no more than 14 calendar days after initiation of services. [...]”

Summary: MDH found the licensee failed to ensure the service plan included a licensee signature or other authentication by the licensee and by the resident to document agreement on the services to be provided for three of six residents (R2, R5, R6).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the service plan included a licensee signature or other authentication by the licensee and by the resident to document agreement on the services to be provided for three of six residents (R2, R5, R6). [...]”

Rule cited: “(a) No later than 14 calendar days after the date that services are first provided, an assisted living facility shall finalize a current written service plan. [...]”

Summary: MDH found the licensee failed to ensure service plans included the required content for three of three residents (R1, R2, R4).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure service plans included the required content for three of three residents (R1, R2, R4). [...]”

Rule cited: “(f) The service plan must include: (1) a description of the services to be provided, the fees for services, and the frequency of each service, according to the resident's current assessment and resident preferences; (2) the identification of staff or [...]”

MDH’s finding, as written: “This correction order was modified on February 14, 2025, to add additional information regarding an interview with RN-J on February 6, 2025. Based on observation, interview, and record review, the licensee failed to ensure prior to delegating the nursing task of medication administration, the registered nurse (RN) instructed the unlicensed personnel (ULP) in proper methods to administer the medications and the ULP demonstrated competency back to the RN for administering medications for two of [...]”

Rule cited: “When administration of medications is delegated to unlicensed personnel, the assisted living facility must ensure that the registered nurse has: (1) instructed the unlicensed personnel in the proper methods to administer the medications, and the unlicensed [...]”

Summary: MDH found the licensee failed to ensure documentation of medication setup included all the required content for one of one resident (R4).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure documentation of medication setup included all the required content for one of one resident (R4). [...]”

Rule cited: “Documentation of dates of medication setup, name of medication, quantity of dose, times to be administered, route of administration, and name of person completing medication setup must be done at the time of setup.”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) developed written procedures for the unlicensed personnel (ULP) providing medications for residents having unplanned time away when the licensed nurse was not available.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) developed written procedures for the unlicensed personnel (ULP) providing medications for residents having unplanned time away when the licensed nurse was not available. In addition, the licensee failed to ensure two of two ULPs (ULP-F, ULP-G) was trained and had demonstrated competency to prepare and give medications for residents having unplanned time away. [...]”

Rule cited: “(2) for unplanned time away, when the pharmacy is not able to provide the medications, a licensed nurse or unlicensed personnel shall provide medications in amounts and dosages needed for the length of the anticipated absence, not to exceed seven calendar [...]”

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure current written or electronically recorded prescriptions were obtained for two of three residents (R1, R4) who received medication management services. [...]”

Rule cited: “There must be a current written or electronically recorded prescription as defined in section 151.01, subdivision 16a, for all prescribed medications that the assisted living facility is managing for the resident.”

Summary: MDH found the licensee failed to ensure medications were securely locked and permitted access to only authorized personnel for medications located inside of a shared office.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were securely locked and permitted access to only authorized personnel for medications located inside of a shared office. This had the potential to affect all four residents, staff, and visitors. This resulted in an immediate correction order identified on February 4, 2025. [...]”

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.”

Summary: MDH found the licensee failed to ensure medications were maintained bearing the original prescription label with legible information including the expiration date for time sensitive medications for three of three residents (R7, R11, R12).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were maintained bearing the original prescription label with legible information including the expiration date for time sensitive medications for three of three residents (R7, R11, R12). [...]”

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 [...]”

MDH’s finding, as written: “This correction order was modified on February 14, 2025, to add additional information regarding an interview with RN-J on February 6, 2025. Based on observation, interview, and record review, the licensee failed to ensure prior to delegating nursing tasks of treatment administration, the unlicensed personnel (ULP) were trained in the proper methods to perform blood glucose testing and the ULP demonstrated competency back to the registered nurse (RN) for two of two employees (ULP-F, ULP-G). [...]”

Rule cited: “Ordered or prescribed treatments or therapies must be administered by a nurse, physician, or other licensed health professional authorized to perform the treatment or therapy, or may be delegated or assigned to unlicensed personnel by the licensed health [...]”

Summary: MDH found the licensee failed to ensure up-to-date written or electronically recorded prescriptions were obtained for two of three residents (R1, R4) who received treatment management services.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure up-to-date written or electronically recorded prescriptions were obtained for two of three residents (R1, R4) who received treatment management services. [...]”

Rule cited: “There must be an up-to-date written or electronically recorded order from an authorized prescriber for all treatments and therapies. [...]”

Summary: MDH found the licensee failed to ensure the care and services were provided according to acceptable health care and medical, or nursing standards for one of one resident (R8) with hospital bedrails.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the care and services were provided according to acceptable health care and medical, or nursing standards for one of one resident (R8) with hospital bedrails. [...]”

Rule cited: “(a) Residents have the right to care and assisted living services that are appropriate based on the resident's needs and according to an up-to-date service plan subject to accepted health care standards.”

Summary: MDH found the licensee failed to ensure one of one resident (R5) was treated with dignity and respect when R5's urinary collection bag was uncovered in the common area of the facility.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one of one resident (R5) was treated with dignity and respect when R5's urinary collection bag was uncovered in the common area of the facility. [...]”

Rule cited: “Residents have the right to be treated with courtesy and respect, and to have the resident's property treated with respect”

Summary: MDH found the licensee failed to ensure privacy was maintained for one of four residents (R7) while receiving services.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure privacy was maintained for one of four residents (R7) while receiving services. 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 affected [...]”

Rule cited: “(a) Residents have the right to consideration of their privacy, individuality, and cultural identity as related to their social, religious, and psychological well-being. [...]”