Alex Assisted Living

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

MDH’s finding, as written: “Based on interview and record review, the facility failed to ensure the contract did not include language waiving the facility's liability for health, safety, or personal property of a resident. This had the potential to affect all residents. [...]”

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 ensure a background study was submitted and received for one of one employee (registered nurse (RN)-O) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a background study was submitted and received for one of one employee (registered nurse (RN)-O) with records reviewed. This resulted in an immediate correction order on January 24, 2022. [...]”

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 have a registered nurse (RN) available for consultation by staff performing delegated nursing tasks.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to have a registered nurse (RN) available for consultation by staff performing delegated nursing tasks. This had the potential to affect all residents. [...]”

Rule cited: “(a) Assisted living facilities must have a registered nurse available for consultation by staff performing delegated nursing tasks and must have an appropriate licensed health professional available if performing other delegated services such as therapies.”

Summary: MDH found the licensee failed to conduct an ongoing resident reassessment and monitoring that reflected the resident's current condition for one of one resident (R5) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to conduct an ongoing resident reassessment and monitoring that reflected the resident's current condition for one of one resident (R5) with records reviewed. [...]”

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 the required content for two of four residents (R1, R2) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the service plan included the required content for two of four residents (R1, R2) with records reviewed. [...]”

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 [...]”

Summary: MDH found the licensee failed to ensure the registered nurse

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) conducted a face-to-face medication management assessment, prior to providing medication management services, to include all required content for three of four residents (R1, R2, R5) with records reviewed. [...]”

Rule cited: “(a) For each resident who requests medication management services, the facility shall, prior to providing medication management services, have a registered nurse, licensed health professional, or authorized prescriber under section 151.37 conduct an [...]”

Summary: MDH found the licensee failed to develop and maintain a current individualized medication management record to include all required content for one of four residents (R2) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and maintain a current individualized medication management record to include all required content for one of four residents (R2) with record reviewed. [...]”

Rule cited: “(a) For each resident receiving medication management services, the assisted living facility must prepare and include in the service plan a written statement of the medication management services that will be provided to the resident. [...]”

Summary: MDH found the licensee failed to ensure written or electronically recorded prescriptions were obtained for one of four residents (R1) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure written or electronically recorded prescriptions were obtained for one of four residents (R1) with records reviewed. [...]”

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 develop a treatment management plan to include all required content for three of four residents receiving treatments (R1, R5 and R21) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop a treatment management plan to include all required content for three of four residents receiving treatments (R1, R5 and R21) with records reviewed. [...]”

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 [...]”

Summary: MDH found the licensee failed to document treatment administration for two of three residents (R1, R5) receiving treatments.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to document treatment administration for two of three residents (R1, R5) receiving treatments. 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 [...]”

Rule cited: “Each treatment or therapy administered by an assisted living facility must be in the resident record. [...]”

Summary: MDH found the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment and complete a thorough investigation for two of two residents (R5 and R19) with records reviewed.

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 and complete a thorough investigation for two of two residents (R5 and R19) with records reviewed. [...]”

Rule cited: “144G.42 Subd. 6. Compliance with requirements for reporting maltreatment of vulnerable adults; abuse prevention plan. (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 ensure the employee file included all required content for one of three employees (registered nurse (RN)-B).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the employee file included all required content for one of three employees (registered nurse (RN)-B). [...]”

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. [...]”

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) current screening for active or latent TB for one of three employees (registered nurse (RN)-B).

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) current screening for active or latent TB for one of three employees (registered nurse (RN)-B). In addition, the licensee failed to ensure TB training was completed for one of three employees (RN-B) with records reviewed. [...]”

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 the service plan section of the contract did not include limitations of provider liability.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the service plan section of the contract did not include limitations of provider liability. This had the potential to affect all residents. [...]”

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 facility failed to ensure the contract did not include language waiving the facility's liability for health, safety, or personal property of a resident.

MDH’s finding, as written: “Based on interview and record review, the facility failed to ensure the contract did not include language waiving the facility's liability for health, safety, or personal property of a resident. This had the potential to affect all residents. [...]”

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 ensure contracted staff met all requirements required for personnel employed by the facility for one of one unlicensed personnel (ULP-H) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure contracted staff met all requirements required for personnel employed by the facility for one of one unlicensed personnel (ULP-H) with records reviewed. [...]”

Rule cited: “When a facility contracts with a temporary staffing agency, those individuals must meet the same requirements required by this section for personnel employed by the facility and shall be treated as if they are staff of the facility.”

Summary: MDH found the facility failed to have a registered nurse available for consultation by staff performing delegated nursing tasks.

MDH’s finding, as written: “Based on interview and record review, the facility failed to have a registered nurse available for consultation by staff performing delegated nursing tasks. This had the potential to affect all residents. [...]”

Rule cited: “(a) Assisted living facilities must have a registered nurse available for consultation by staff performing delegated nursing tasks and must have an appropriate licensed health professional available if performing other delegated services such as therapies.”

Summary: MDH found the licensee failed to ensure all required content of orientation was provided to one of three employees (registered nurse (RN)-B).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure all required content of orientation was provided to one of three employees (registered nurse (RN)-B). [...]”

Rule cited: “(a) The orientation must contain the following topics: (1) an overview of this chapter; (2) an introduction and review of the facility's policies and procedures related to the provision of assisted living services by the individual staff person; (3) handling [...]”

Summary: MDH found the licensee failed to ensure all staff received dementia care as required for two of two employees (registered nurse (RN)-B, unlicensed personnel (ULP)-G).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure all staff received dementia care as required for two of two employees (registered nurse (RN)-B, unlicensed personnel (ULP)-G). [...]”

Rule cited: “All direct care staff and supervisors providing direct services must demonstrate an understanding of the training specified in section 144G.64.”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) had assessed three of three residents (R1, R2, R3) prior to initiating medication management services with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the registered nurse (RN) had assessed three of three residents (R1, R2, R3) prior to initiating medication management services with records reviewed. [...]”

Rule cited: “(a) For each resident who requests medication management services, the facility shall, prior to providing medication management services, have a registered nurse, licensed health professional, or authorized prescriber under section 151.37 conduct an [...]”

Summary: MDH found the licensee failed to develop and maintain a current individualized medication management record for each resident to include all required content for three of three residents (R1, R2, R3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop and maintain a current individualized medication management record for each resident to include all required content for three of three residents (R1, R2, R3) with records reviewed. [...]”

Rule cited: “(a) For each resident receiving medication management services, the assisted living facility must prepare and include in the service plan a written statement of the medication management services that will be provided to the resident. [...]”

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 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. [...]”

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 [...]”

Summary: MDH found the licensee failed to ensure medications were stored according to manufacturer's instructions for one of one medication refrigerator.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure medications were stored according to manufacturer's instructions for one of one medication refrigerator. [...]”

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 with the open date and the expiration date for time sensitive medications for six of six residents (R2, R3, R7, R11, R12 and R13).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure medications were maintained with the open date and the expiration date for time sensitive medications for six of six residents (R2, R3, R7, R11, R12 and R13). [...]”

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 [...]”

Summary: MDH found the licensee failed to maintain documentation of treatment administration for two of two residents (R1 and R3) who received treatments.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to maintain documentation of treatment administration for two of two residents (R1 and R3) who received treatments. [...]”

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 [...]”

Summary: MDH found the licensee failed ensure up-to-date written or electronically recorded orders were maintained for one of two residents (R1) receiving treatments.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed ensure up-to-date written or electronically recorded orders were maintained for one of two residents (R1) receiving treatments. [...]”

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 maintain a dignified dining experience for three of three residents requiring assistance with meals (R1, R5, R20) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to maintain a dignified dining experience for three of three residents requiring assistance with meals (R1, R5, R20) with records reviewed. [...]”

Rule cited: “The licensee of an assisted living facility with dementia care is responsible for the care and housing of the persons with dementia and the provision of person-centered care that promotes each resident's dignity, independence, and comfort. [...]”

Summary: MDH found the licensee failed to ensure staff working in the dementia care unit were trained in person-centered care approach for one of one unlicensed personnel (ULP-H).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure staff working in the dementia care unit were trained in person-centered care approach for one of one unlicensed personnel (ULP-H). [...]”

Rule cited: “(a) An assisted living facility with dementia care must provide residents with dementia-trained staff who have been instructed in the person-centered care approach. [...]”

Summary: MDH found the licensee failed to ensure the care and services were provided according to a suitable and up-to-date plan, and subject to acceptable health care and medical, or nursing standards for one of one resident with pressure ulcers (R5) and two of three residents with side rails (R1 and R2),

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 a suitable and up-to-date plan, and subject to acceptable health care and medical, or nursing standards for one of one resident with pressure ulcers (R5) and two of three residents with side rails (R1 and R2), with records reviewed. [...]”

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 properly train and to ensure competency in knowing when to notify the registered nurse (RN) of resident related changes in condition for two of two employees (unlicensed personnnel (ULP)-I and licensed practical nurse (LPN)-J).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to properly train and to ensure competency in knowing when to notify the registered nurse (RN) of resident related changes in condition for two of two employees (unlicensed personnnel (ULP)-I and licensed practical nurse (LPN)-J). [...]”

Rule cited: “(b) Residents have the right to receive health care and other assisted living services with continuity from people who are properly trained and competent to perform their duties and in sufficient numbers to adequately provide the services agreed to in the [...]”

Summary: MDH found the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center

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 and complete a thorough investigation for two of two residents (R5 and R19) with records reviewed. [...]”

Rule cited: “(a) A mandated reporter who has reason to believe that a vulnerable adult is being or has been maltreated, or who has knowledge that a vulnerable adult has sustained a physical injury which is not reasonably explained shall immediately report the information [...]”