Amia Assisted Living

Summary: MDH found the licensee failed to ensure that a registered nurse (RN) was available on-call 24 hours a day, seven days per week.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure that a registered nurse (RN) was available on-call 24 hours a day, seven days per week. This had the potential to affect all residents and staff of the facility. [...]”

Rule cited: “(13) provide staff access to an on-call registered nurse 24 hours per day, seven days per week.”

Summary: MDH found the licensee failed to implement and maintain a quality management program (QMP) 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 (QMP) appropriate to the size of the facility and relevant to the type of services provided. This had the potential to affect all 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 ensure an individual abuse prevention plan (IAPP) was developed to include the required content for one of one resident (R1).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure an individual abuse prevention plan (IAPP) was developed to include the 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 ensure employee records included all required content for three of three employees (unlicensed personnel (ULP)-B,

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure employee records included all required content for three of three employees (unlicensed personnel (ULP)-B, owner/unlicensed personnel (O/ULP)-D, and owner/licensed practical nurse (O/LPN)-A). [...]”

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 TB facility risk assessment and a two-step tuberculin skin test (TST) or other evidence of TB screening such as a blood test for two of three employees (owner/licensed practical nurse (O/LPN)-A, owner/unlicensed personnel (O/ULP)-D).

MDH’s finding, as written: “Based on observation, 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 TB facility risk assessment and a two-step tuberculin skin test (TST) or other evidence of TB screening such as a blood test for two of three employees (owner/licensed practical nurse (O/LPN)-A, owner/unlicensed personnel (O/ULP)-D). [...]”

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 maintain a written emergency preparedness plan (EPP) with all the required content as defined in Appendix Z. This had the potential to affect all residents, staff, and visitors.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to maintain a written emergency preparedness plan (EPP) with all the required content as defined in Appendix Z. 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 personal health and medical information was kept private for one of one resident (R1).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure personal health and medical information was kept private for one of one resident (R1). [...]”

Rule cited: “(b) Resident records, whether written or electronic, must be protected against loss, tampering, or unauthorized disclosure in compliance with chapter 13 and other applicable relevant federal and state laws. [...]”

Summary: MDH found the licensee failed to ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G. [...]”

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 ensure the physical

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G. [...]”

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 ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G. [...]”

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

Summary: MDH found the licensee failed to provide a written notice with the required content for an emergency relocation to the resident, legal representative, or designated representative for one of one resident with an emergency relocation (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a written notice with the required content for an emergency relocation to the resident, legal representative, or designated representative for one of one resident with an emergency relocation (R1). [...]”

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 a registered nurse (RN) conducted direct supervision of staff performing a delegated task within 30 days of providing services for two of two unlicensed personnel (ULP) (ULP-B, owner/unlicensed personnel (O/ULP)-D).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a registered nurse (RN) conducted direct supervision of staff performing a delegated task within 30 days of providing services for two of two unlicensed personnel (ULP) (ULP-B, owner/unlicensed personnel (O/ULP)-D). [...]”

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 [...]”

MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to provide supervisors of direct-care staff at least eight hours of initial training on dementia topics specified under paragraph (b) clauses (1) to (5) and two hours of initial training on mental illness and de-escalation topics specified under paragraph (b), clauses (6) to (8), within 120 working hours of the employment state date and failed to provide direct-care staff at least eight hours of initial training on dementia [...]”

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 conduct an initial nursing assessment completed by a registered nurse (RN) of the physical and cognitive needs for one of one resident (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to conduct an initial nursing assessment completed by a registered nurse (RN) of the physical and cognitive needs for one of one resident (R1). [...]”

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 conduct ongoing nursing

MDH’s finding, as written: “Based on interview, and record review, the licensee failed to conduct ongoing nursing assessments completed by a registered nurse (RN) of the physical and cognitive needs for one of one resident. (R1). [...]”

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 finalize a current written service plan that included a signature or other authentication by the facility and by the resident documenting an agreement on the services to be provided for one of one resident (R1).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to finalize a current written service plan that included a signature or other authentication by the facility and by the resident documenting an agreement on the services to be provided for one of one resident (R1). In addition, the licensee failed to implement the service plan for one of one resident (R1). [...]”

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 dispose of

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to dispose of medication according to their policy and State and Federal regulations for disposition of medication. [...]”

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

Summary: MDH found the licensee failed to maintain a current individualized medication plan to include documentation of specific resident instructions related to the administration of medications for one of one resident (R1).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to maintain a current individualized medication plan to include documentation of specific resident instructions related to the administration of medications for one of one resident (R1). [...]”

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 written or electronically recorded prescriptions were obtained for one of one resident (R1).

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 one resident (R1). 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 or [...]”

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, medical, or nursing standards for one of one resident (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, medical, or nursing standards for one of one resident (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.”