American Spirit

Summary: MDH found the licensee failed to implement and maintain a quality management program 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 implement and maintain a quality management program appropriate to the size of the facility and relevant to the type of services provided. This had the potential to affect all current residents, staff, and visitors. [...]”

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 maintain current records of each paid staff member, each regularly scheduled volunteer providing services, and each individual contractor providing services for two of two employees (assisted living director in residency/licensed practical nurse (ALDIR/LPN)-A, unlicensed personnel (ULP)-C).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to maintain current records of each paid staff member, each regularly scheduled volunteer providing services, and each individual contractor providing services for two of two employees (assisted living director in residency/licensed practical nurse (ALDIR/LPN)-A, unlicensed personnel (ULP)-C). [...]”

Rule cited: “(a) The facility must maintain current records of each paid staff member, each regularly scheduled volunteer providing services, and each individual contractor providing services. [...]”

Summary: MDH found the licensee failed to maintain a tuberculosis (TB) prevention and control program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC), to include a facility TB risk assessment, history and symptom screening and baseline testing for two of two employees (assisted living director-in-residency/licensed practical nurse (ALDIR/LPN)-A and unlicensed personnel (ULP)-C).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to maintain a tuberculosis (TB) prevention and control program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC), to include a facility TB risk assessment, history and symptom screening and baseline testing for two of two employees (assisted living director-in-residency/licensed practical nurse (ALDIR/LPN)-A and unlicensed personnel (ULP)-C). [...]”

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 have a written emergency preparedness (EP) plan with all the required content.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to have a written emergency preparedness (EP) plan with all the required content. 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 maintain facility in compliance with Minnesota State Fire Code under Minnesota Rules Chapter 7511.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain facility in compliance with Minnesota State Fire Code under Minnesota Rules Chapter 7511. This had the potential to 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 maintain the portable fire extinguishers.

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

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.

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. 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 develop and execute a written assisted living contract with the required content for three of three residents (R2, R3, R4).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and execute a written assisted living contract with the required content for three of three residents (R2, R3, R4). [...]”

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 registered nurse (RN) The completed direct supervision of staff performing delegated tasks within 30 calendar days after the date on which the individual began working for the facility and first performed the delegated task for two of two employees (unlicensed personnel (ULP)-C and ULP-E).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) The completed direct supervision of staff performing delegated tasks within 30 calendar days after the date on which the individual began working for the facility and first performed the delegated task for two of two employees (unlicensed personnel (ULP)-C and ULP-E). [...]”

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 facility licensing requirements and regulations for two of two

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received orientation to assisted living facility licensing requirements and regulations for two of two employees (unlicensed personnel (ULP)-C and ULP-E). [...]”

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 the required dementia care training and two hours of initial mental illness and de-escalation training were completed within required timeframe for two of two employees (unlicensed personnel (ULP)-C and ULP-E).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the required dementia care training and two hours of initial mental illness and de-escalation training were completed within required timeframe for two of two employees (unlicensed personnel (ULP)-C and ULP-E). [...]”

Rule cited: “(a) All assisted living facilities must meet the following dementia care, mental illness, and de-escalation training requirements: (1) supervisors of direct-care staff must have at least eight hours of initial training on dementia topics specified under [...]”

Summary: MDH found the licensee failed to ensure a written service plan was developed, including a signature or other authentication by the facility and by the resident documenting agreement on the services to be provided for three of three residents (R2, R3, R4).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a written service plan was developed, including a signature or other authentication by the facility and by the resident documenting agreement on the services to be provided for three of three residents (R2, R3, R4). [...]”

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 develop, implement, 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 observation, interview and record review, the licensee failed to develop, implement, 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 discard expired medications and failed to label medications with the appropriate resident's name for one of three residents (R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to discard expired medications and failed to label medications with the appropriate resident's name for one of three residents (R3). [...]”

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 develop and implement current policies and procedures as required.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and implement current policies and procedures as required. 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 is issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the [...]”

Rule cited: “Each assisted living facility must have policies and procedures in place to address the following and keep them current: (1) requirements in section 626.557, reporting of maltreatment of vulnerable adults; (2) conducting and handling background studies on [...]”

Summary: MDH found the licensee failed to support protection and safety by not posting the facilities' grievance procedure, with the current name, telephone number, and email contact information for the individuals who are responsible for handling resident grievances.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to support protection and safety by not posting the facilities' grievance procedure, with the current name, telephone number, and email contact information for the individuals who are responsible for handling resident grievances. This had the potential to affect all residents, staff, and visitors of the facility. [...]”

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 implement and maintain a quality management program 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 implement and maintain a quality management program appropriate to the size of the facility and relevant to the type of services provided. This had the potential to affect all current residents, staff, and visitors. [...]”

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 maltreatment and neglect to the Minnesota Adult Abuse Reporting Center (MAARC) for one of four residents (R1).

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

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 ensure an individual abuse prevention plan (IAPP) was developed to include all required content for one of one resident (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure an individual abuse prevention plan (IAPP) was developed to include all required content for one of one resident (R1). [...]”

Rule cited: “(b) The facility must develop and implement an individual abuse prevention plan for each vulnerable adult. [...]”

Summary: MDH found the licensee failed to maintain current records of each paid staff member, each regularly scheduled volunteer providing services, and each individual contractor providing services for two of two employees (assisted living director in residency/licensed practical nurse (ALDIR/LPN)-A, unlicensed personnel (ULP)-C).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to maintain current records of each paid staff member, each regularly scheduled volunteer providing services, and each individual contractor providing services for two of two employees (assisted living director in residency/licensed practical nurse (ALDIR/LPN)-A, unlicensed personnel (ULP)-C). [...]”

Rule cited: “(a) The facility must maintain current records of each paid staff member, each regularly scheduled volunteer providing services, and each individual contractor providing services. [...]”

Summary: MDH found the licensee failed to maintain a tuberculosis (TB) prevention and control program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC), to include a facility TB risk assessment, history and symptom screening and baseline testing for two of two employees (assisted living director-in-residency/licensed practical nurse (ALDIR/LPN)-A and unlicensed personnel (ULP)-C).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to maintain a tuberculosis (TB) prevention and control program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC), to include a facility TB risk assessment, history and symptom screening and baseline testing for two of two employees (assisted living director-in-residency/licensed practical nurse (ALDIR/LPN)-A and unlicensed personnel (ULP)-C). [...]”

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 have a written

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 the required content. 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 [...]”

MDH’s finding, as written: “Based on interview and record review the licensee failed to ensure the resident records contained all required contents for four of four residents (R1, R2, R3, R4). 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 a widespread scope (when problems are pervasive or represent a systemic [...]”

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 maintain facility in compliance with Minnesota State Fire Code under Minnesota Rules Chapter 7511.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain facility in compliance with Minnesota State Fire Code under Minnesota Rules Chapter 7511. This had the potential to 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 maintain the portable fire extinguishers.

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

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. 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 develop and execute a written assisted living contract with the required content for four of four residents (R1, R2, R3, R4).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and execute a written assisted living contract with the required content for four of four residents (R1, R2, R3, R4). [...]”

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 all employees had a cleared department of human services (DHS) background study affiliated with the assisted living licensee's current health facility identification (HFID) for one of six employees (unlicensed personnel (ULP)-C).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure all employees had a cleared department of human services (DHS) background study affiliated with the assisted living licensee's current health facility identification (HFID) for one of six employees (unlicensed personnel (ULP)-C). [...]”

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 the registered nurse (RN) The completed direct supervision of staff performing delegated tasks within 30 calendar days after the date on which the individual began working for the facility and first performed the delegated task for two of two employees (unlicensed personnel (ULP)-C and ULP-E).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) The completed direct supervision of staff performing delegated tasks within 30 calendar days after the date on which the individual began working for the facility and first performed the delegated task for two of two employees (unlicensed personnel (ULP)-C and ULP-E). [...]”

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 facility licensing requirements and regulations for two of two employees (assisted living director in residency/licensed practical nurse (ALDIR/LPN)-A and unlicensed personnel (ULP)-C).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received orientation to assisted living facility licensing requirements and regulations for two of two employees (assisted living director in residency/licensed practical nurse (ALDIR/LPN)-A and unlicensed personnel (ULP)-C). [...]”

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 required dementia care training and two hours of initial mental illness and de-escalation training were conducted within required timeframe for two of two employees (assisted living director in residency/licensed practical nurse (ALDIR/LPN)-A and unlicensed personnel (ULP)-C).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure required dementia care training and two hours of initial mental illness and de-escalation training were conducted within required timeframe for two of two employees (assisted living director in residency/licensed practical nurse (ALDIR/LPN)-A and unlicensed personnel (ULP)-C). [...]”

Rule cited: “(a) All assisted living facilities must meet the following dementia care, mental illness, and de-escalation training requirements: (1) supervisors of direct-care staff must have at least eight hours of initial training on dementia topics specified under [...]”

MDH’s finding, as written: “Based on observation, interview and record review the licensee failed to ensure the registered nurse (RN) completed initial and ongoing comprehensive reassessments using the uniform assessment tool at an interval not to exceed 90 days for four of four residents (R1, R2, R3, R4). [...]”

Rule cited: “(a) Residents who are not receiving any assisted living services shall not be required to undergo an initial nursing assessment. [...]”

Summary: MDH found the licensee failed to ensure a written service plan was developed, including a signature or other authentication by the facility and by the resident documenting agreement on the services to be provided for four of four residents (R1, R2, R3, R4).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a written service plan was developed, including a signature or other authentication by the facility and by the resident documenting agreement on the services to be provided for four of four residents (R1, R2, R3, R4). [...]”

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 develop, implement, 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 observation, interview and record review, the licensee failed to develop, implement, 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) completed face-to-face medication management assessments at least annually for four of four residents (R1, R2, R3, R4).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) completed face-to-face medication management assessments at least annually for four of four residents (R1, R2, R3, R4). [...]”

Rule cited: “A registered nurse, advanced practice registered nurse, or qualified staff delegated the task by a registered nurse must monitor and reassess the resident's medication management services as needed under subdivision 2 when the resident presents with symptoms [...]”

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 four of four residents (R1, R2, R3, R4).

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 four of four residents (R1, R2, R3, R4). [...]”

Rule cited: “(a) For each resident receiving medication management services, a registered nurse, advanced practice registered nurse, or qualified staff delegated the task by a registered nurse must prepare and include in the service plan a written statement of the [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) instructed the unlicensed personnel (ULP) in the proper medication administration procedure, and the ULP had demonstrated the ability to competently follow the procedure prior to delegating medication administration, for two of two employees (ULP-C, ULP-E).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the registered nurse (RN) instructed the unlicensed personnel (ULP) in the proper medication administration procedure, and the ULP had demonstrated the ability to competently follow the procedure prior to delegating medication administration, for two of two employees (ULP-C, ULP-E). [...]”

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 medications were documented as administered per provider orders, or why medication administration was not completed as prescribed for three of three residents with medication administration (R1, R2, and R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were documented as administered per provider orders, or why medication administration was not completed as prescribed for three of three residents with medication administration (R1, R2, and R3). [...]”

Rule cited: “Each medication administered by the assisted living facility staff must be documented in the resident's record. The documentation must include the signature and title of the person who administered the medication. [...]”

Summary: MDH found the licensee failed to ensure there were current written or electronically recorded prescriptions as defined in section 151.01, subdivision 16a, for all prescribed medications that the assisted living facility was managing for three of three residents (R1, R2, and R3).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure there were current written or electronically recorded prescriptions as defined in section 151.01, subdivision 16a, for all prescribed medications that the assisted living facility was managing for three of three residents (R1, R2, and R3). [...]”

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 provide care and services according to acceptable health care standards, medical or nursing standards for one of one residents (R1) who utilized bed rails.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to provide care and services according to acceptable health care standards, medical or nursing standards for one of one residents (R1) who utilized bed rails. [...]”

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.”