American Eagle Owatonna (Assisted Living)

Summary: MDH found the licensee failed to post in a conspicuous place, information about the facility's grievance procedure with the required content.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to post in a conspicuous place, information about the facility's grievance procedure with the required content. This had the potential to affect the licensee's 15 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 e-mail contact information for the individuals who are responsible for handling resident grievances. [...]”

Summary: MDH found the licensee failed to support protection and safety through access to the state's systems

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to support protection and safety through access to the state's systems for reporting suspected criminal activity and suspected vulnerable adult maltreatment as required. This had the potential to affect all of the licensee's current 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 establish and maintain a tuberculosis (TB) prevention program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC), which included a current facility TB risk assessment, and completion of a two-step tuberculin skin test

MDH’s finding, as written: “Based on interview and record review, the licensee failed to establish and maintain a tuberculosis (TB) prevention program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC), which included a current facility TB risk assessment, and completion of a two-step tuberculin skin test (TST) or other evidence of TB screening such as a blood test, for one of four employees (registered nurse (RN)-C) 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 [...]”

MDH’s finding, as written: “Based on observation, interview and record review the licensee failed to have a written emergency preparedness (EP) plan with all of the required content and failed to provide building emergency exit diagrams to all residents. This had the potential to affect all residents, staff and visitors. [...]”

Rule cited: “(a) The facility must meet the following requirements: (1) have a written emergency disaster plan that contains a plan for evacuation, addresses elements of sheltering in place, identifies temporary relocation sites, and details staff assignments in the event [...]”

Summary: MDH found the licensee failed to ensure resident records included a discharge summary with the required content for one of one discharged resident (R1) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure resident records included a discharge summary with the required content for one of one discharged resident (R1) with record reviewed. [...]”

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 install and maintain fire extinguishers in accordance to MNSFC provisions.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to install and maintain fire extinguishers in accordance to MNSFC provisions. This had the potential to directly 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 facility failed to maintain the facility in good repair in regards to resident health and safety in accordance with maintenance and repair program.

MDH’s finding, as written: “Based on observation, and staff interview, the facility failed to maintain the facility in good repair in regards to resident health and safety in accordance with maintenance and repair program. This deficient condition has the ability to affect all staff and residents. [...]”

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 facility failed have detailed fire safety and evacuation plans and associated confirming documentation.

MDH’s finding, as written: “Based on observation, and staff interview, the facility failed have detailed fire safety and evacuation plans and associated confirming documentation. This deficient condition has the ability to affect all staff and residents. [...]”

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

Summary: MDH found the licensee failed to provide to the Office of Ombudsman for Long-Term Care a complete unsigned copy of its contract.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide to the Office of Ombudsman for Long-Term Care a complete unsigned copy of its contract. This had the potential to affect all current 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 licensee failed to execute a written contract with the required content for two of two residents (R2, R3) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract with the required content for two of two residents (R2, R3) with records reviewed. [...]”

Rule cited: “(a) The contract must include in a conspicuous place and manner on the contract the legal name and the license number of the facility. [...]”

Summary: MDH found the licensee failed to execute a written assisted living contract with the required content for two of two residents (R2, R3) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written assisted living contract with the required content for two of two residents (R2, R3) with records reviewed. [...]”

Rule cited: “(c) The contract must include: (1) a disclosure of the category of assisted living facility license held by the facility and, if the facility is not an assisted living facility with dementia care, a disclosure that it does not hold an assisted living facility [...]”

Summary: MDH found the licensee failed to execute a written assisted living contract with the required content for two of two residents (R2, R3) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written assisted living contract with the required content for two of two residents (R2, R3) with records reviewed. This had the potential to affect all 15 residents. [...]”

Rule cited: “(d) The contract must include a description of the facility's complaint resolution process available to residents, including the name and contact information of the person representing the facility who is designated to handle and resolve complaints. [...]”

Summary: MDH found the licensee failed to execute a written contract with the required content for two of two residents (R2, R3) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract with the required content for two of two residents (R2, R3) with records reviewed. [...]”

Rule cited: “(5) a description of the facility's policies related to medical assistance waivers under chapter 256S and section 256B.49 and the housing support program under chapter 256I, including: (i) whether the facility is enrolled with the commissioner of human [...]”

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.

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. 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 background studies were conducted prior to staff providing services, for one of four employees (registered nurse (RN)-C) with employee records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure background studies were conducted prior to staff providing services, for one of four employees (registered nurse (RN)-C) with employee records reviewed. [...]”

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) conducted supervision of unlicensed staff as required for two of two employees (unlicensed personnel (ULP)-E, ULP-F) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a registered nurse (RN) conducted supervision of unlicensed staff as required for two of two employees (unlicensed personnel (ULP)-E, ULP-F) with records reviewed. [...]”

Rule cited: “(a) Staff who perform delegated nursing or therapy tasks must be supervised by an appropriate licensed health professional or a registered nurse according to the assisted living facility's policy where the services are being provided to verify that the work [...]”

Summary: MDH found the licensee failed to ensure employees received orientation to assisted living licensing requirements and regulations prior to providing services for three of three employees (registered nurse (RN)-C, unlicensed personnel (ULP)-E, ULP-F) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received orientation to assisted living licensing requirements and regulations prior to providing services for three of three employees (registered nurse (RN)-C, unlicensed personnel (ULP)-E, ULP-F) with records reviewed. [...]”

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 two of four employees (unlicensed personnel (ULP)-E, ULP-F) received the required amount of dementia care training, in the required time frame with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure two of four employees (unlicensed personnel (ULP)-E, ULP-F) received the required amount of dementia care training, in the required time frame with records reviewed. [...]”

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: “Based on interview and record review, the licensee failed to provide in written or electronic form to residents, families, or other persons who request it, a description of the dementia care training program, the categories of employees trained, the frequency of training, and the basic topics covered. This had the potential to affect all residents. [...]”

Rule cited: “(5) new employees may satisfy the initial training requirements by producing written proof of previously completed required training within the past 18 months. [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) completed resident reassessment and monitoring no more than 14 calendar days after initiation of services, and within 90 calendar days from the last date of the assessment using the uniform assessment tool for one of one resident (R3) as required, with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the registered nurse (RN) completed resident reassessment and monitoring no more than 14 calendar days after initiation of services, and within 90 calendar days from the last date of the assessment using the uniform assessment tool for one of one resident (R3) as required, 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 a current written service plan was revised to reflect the current services provided for two of two residents (R2, R3), with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a current written service plan was revised to reflect the current services provided for two of two residents (R2, R3), with records reviewed. [...]”

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 the service plan included the required content for two of two residents (R2, R3) 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 two residents (R2, R3) 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 develop and maintain current written medication management policies and procedures that were developed under the supervision and direction of a registered nurse (RN).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and maintain current written medication management policies and procedures that were developed under the supervision and direction of a registered nurse (RN). [...]”

Rule cited: “(a) This section applies only to assisted living facilities that provide medication management services. [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) conducted an individualized medication assessment with the required content for two of two residents (R2, R3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the registered nurse (RN) conducted an individualized medication assessment with the required content for two of two residents (R2, R3) 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 an individualized medication management plan prior to providing medication management services, and with the required content, for two of two residents (R2, R3), with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop an individualized medication management plan prior to providing medication management services, and with the required content, for two of two residents (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 implement policies and procedures for giving accurate and current medications for those residents who received medication management services during planned times away from home.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to implement policies and procedures for giving accurate and current medications for those residents who received medication management services during planned times away from home. This had the potential to affect all 13 residents receiving medication management services. [...]”

Rule cited: “(a) An assisted living facility that is providing medication management services to the resident must develop and implement policies and procedures for giving accurate and current medications to residents for planned or unplanned times away from home [...]”

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

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) developed comprehensive written procedures for the unlicensed personnel (ULP) providing medications for residents having unplanned time away when the licensed nurse was not available, with records reviewed. [...]”

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 develop and implement procedures for loss and spillage of all controlled substances defined in Minnesota Rules part 6800.4220.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop and implement procedures for loss and spillage of all controlled substances defined in Minnesota Rules part 6800.4220. [...]”

Rule cited: “(a) Assisted living facilities providing medication management must develop and implement procedures for loss or spillage of all controlled substances defined in Minnesota Rules, part 6800.4220. [...]”

Summary: MDH found the licensee failed to develop, implement and maintain up-to-date written treatment or therapy management policies and procedures that were developed under the supervision and direction of a registered nurse (RN) consistent with current practice standards and guidelines, with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop, implement and maintain up-to-date written treatment or therapy management policies and procedures that were developed under the supervision and direction of a registered nurse (RN) consistent with current practice standards and guidelines, with records reviewed. [...]”

Rule cited: “(a) An assisted living facility that provides treatment and therapy management services must develop, implement, and maintain up-to-date written treatment or therapy management policies and procedures. [...]”

Summary: MDH found the licensee failed to develop and implement a treatment or therapy management plan to include all required content for two of two residents (R2, R3) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and implement a treatment or therapy management plan to include all required content for two of two residents (R2, R3) 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 ensure the care and services were provided according to acceptable health care and medical, or nursing standards for two of three residents (R2, R4) with an assistive device attached to their beds.

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 two of three residents (R2, R4) with an assistive device attached to their beds. [...]”

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.”