Amira Choice Champlin

Summary: MDH found the licensee failed to ensure six of six employees, unlicensed personnel (ULP)-E, ULP-G, ULP-L, ULP-O, ULP-P and ULP-Q, completed training and competency evaluations in all required training topics.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure six of six employees, unlicensed personnel (ULP)-E, ULP-G, ULP-L, ULP-O, ULP-P and ULP-Q, completed training and competency evaluations in all required training topics. This had the potential to affect all residents receiving services. [...]”

Rule cited: “(b) Unlicensed personnel performing delegated nursing tasks in an assisted living facility must: (1) have successfully completed training and demonstrated competency by successfully completing a written or oral test of the topics in section 144G.61, [...]”

Summary: MDH found the licensee failed to ensure a registered nurse (RN) conducted training and competency evaluations in accordance with 144G statutes for six of six employees, unlicensed personnel (ULP)-E, ULP-G, ULP-L, ULP-O, ULP-P and ULP-Q, who performed delegated tasks.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a registered nurse (RN) conducted training and competency evaluations in accordance with 144G statutes for six of six employees, unlicensed personnel (ULP)-E, ULP-G, ULP-L, ULP-O, ULP-P and ULP-Q, who performed delegated tasks. This had the potential to affect all residents receiving services. [...]”

Rule cited: “(b) When the registered nurse or licensed health professional delegates tasks to unlicensed personnel, that person must ensure that prior to the delegation the unlicensed personnel is trained in the proper methods to perform the tasks or procedures for each [...]”

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 assisted living services in accordance with 144G statutes for six of six employees, unlicensed personnel (ULP)-E, ULP-G, ULP-L, ULP-O, ULP-P and ULP-Q, who performed delegated tasks.

MDH’s finding, as written: “Based on 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 assisted living services in accordance with 144G statutes for six of six employees, unlicensed personnel (ULP)-E, ULP-G, ULP-L, ULP-O, ULP-P and ULP-Q, who performed delegated tasks. This had the potential to affect all residents receiving services. [...]”

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 orientation to assisted living licensing requirements and regulations was provided for six of six employees, unlicensed personnel (ULP)-E, ULP-G, ULP-L, ULP-O, ULP-P and ULP-Q, with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure orientation to assisted living licensing requirements and regulations was provided for six of six employees, unlicensed personnel (ULP)-E, ULP-G, ULP-L, ULP-O, ULP-P and ULP-Q, with records reviewed. This had the potential to affect all residents receiving services. [...]”

Rule cited: “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 staff providing assisted living services were oriented specifically to each individual resident and the services to be provided to individual residents for six of six employees, unlicensed personnel (ULP)-E, ULP-G, ULP-L, ULP-O, ULP-P and ULP-Q, with records reviewed.

MDH’s finding, as written: “Based on interview, and record review, the licensee failed to ensure staff providing assisted living services were oriented specifically to each individual resident and the services to be provided to individual residents for six of six employees, unlicensed personnel (ULP)-E, ULP-G, ULP-L, ULP-O, ULP-P and ULP-Q, with records reviewed. This had the potential to affect all residents receiving services. [...]”

Rule cited: “Staff providing assisted living services must be oriented specifically to each individual resident and the services to be provided. This orientation may be provided in person, orally, in writing, or electronically.”

Summary: MDH found the licensee failed to ensure employees received at least eight hours of annual training for each 12 months of employment for three of three employees, unlicensed personnel (ULP)-E, ULP-G, and ULP-O, with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received at least eight hours of annual training for each 12 months of employment for three of three employees, unlicensed personnel (ULP)-E, ULP-G, and ULP-O, with records reviewed. This had the potential to affect all residents receiving services. [...]”

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 a registered nurse (RN) completed the medication management assessment for one of five residents (R20) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a registered nurse (RN) completed the medication management assessment for one of five residents (R20) 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 ensure three of three unlicensed personnel (ULP)-E, ULP-G, and ULP-L demonstrated competency for administering medications.

MDH’s finding, as written: “Based on interview, observation, and record review, the licensee failed to ensure three of three unlicensed personnel (ULP)-E, ULP-G, and ULP-L demonstrated competency for administering medications. This had the potential to affect all residents receiving services. [...]”

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 open medication was labeled with the expiration date

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure open medication was labeled with the expiration date for time sensitive multi-use medication containers for three residents (R7, R24, R25). [...]”

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 ensure unlicensed personnel were trained and demonstrated competency in treatments to a registered nurse (RN) for one of one unlicensed personnel (ULP-E) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure unlicensed personnel were trained and demonstrated competency in treatments to a registered nurse (RN) for one of one unlicensed personnel (ULP-E) with records reviewed. [...]”

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 [...]”

MDH’s finding, as written: “NO FURTHER ACTION”

Rule cited: “An assisted living facility with dementia care that has a secured dementia care unit must meet the requirements of section 144G.45 and the following additional requirements: (1) a hazard vulnerability assessment or safety risk must be performed on and around [...]”

Summary: MDH found the licensee failed to develop individualized activity plans based on the activity assessments for three of three residents (R20, R21, R22) residing on the memory care unit with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop individualized activity plans based on the activity assessments for three of three residents (R20, R21, R22) residing on the memory care unit with records reviewed. [...]”

Rule cited: “(b) Each resident must be evaluated for activities according to the licensing rules of the facility. [...]”

Summary: MDH found the licensee failed to ensure food was prepared and served according to the Minnesota Food Code.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure food was prepared and served according to the Minnesota Food Code. 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) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large portion or all the [...]”

Rule cited: “(13) offer to provide or make available at least the following services to residents: (i) at least three nutritious meals daily with snacks available seven days per week, according to the recommended dietary allowances in the United States Department of [...]”

Summary: MDH found the licensee failed to ensure staff followed infection control standards including hand hygiene and cleaning protocols during medication administration and blood glucose checks for 5 of 18 residents (R4, R10, R11, R17, R18) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure staff followed infection control standards including hand hygiene and cleaning protocols during medication administration and blood glucose checks for 5 of 18 residents (R4, R10, R11, R17, R18) with records reviewed. [...]”

Rule cited: “(a) All assisted living facilities must establish and maintain an infection control program that complies with accepted health care, medical, and nursing standards for infection control. [...]”

Summary: MDH found the licensee failed to ensure individual abuse prevention plans (IAPP) containing all required content were completed on 9 of 10 residents (R1, R2, R5, R6, R7, R13, R14, R15, R16) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure individual abuse prevention plans (IAPP) containing all required content were completed on 9 of 10 residents (R1, R2, R5, R6, R7, R13, R14, R15, R16) with records reviewed. [...]”

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

MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to develop a written emergency disaster preparedness plan with all the required content and failed to post an emergency preparedness plan prominently. This had the potential to affect all residents receiving services under the assisted living license. [...]”

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 remained locked in a secured area.

MDH’s finding, as written: “Based on observation, interview, the licensee failed to ensure resident records remained locked in a secured area. This had the potential to affect all residents. 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) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large [...]”

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 provide records in a timely manner to the Minnesota Department of Health (MDH) on behalf of the commissioner when requested.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide records in a timely manner to the Minnesota Department of Health (MDH) on behalf of the commissioner when requested. [...]”

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. [...]”

MDH’s finding, as written: “Based on interview and record review the licensee failed to complete a discharge summary for three of three discharged residents (R19, R20, R21) with records reviewed. This practice resulted in a level one violation (a violation that has no potential to cause more than a minimal impact on the resident and does not affect health or safety) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large [...]”

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 provide smoke alarms that are interconnected throughout the facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide smoke alarms that are interconnected throughout the facility. This had the ability to affect all staff and residents. [...]”

Rule cited: “(a) Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and: (1) for dwellings or sleeping units, as defined in the State Fire Code: (i) provide smoke alarms in each room used for sleeping purposes; (ii) [...]”

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 and staff. [...]”

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 a fire safety and evacuation plan with required elements, failed to provide required employee and resident training on fire safety and evacuation, and failed to conduct required evacuation drills.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop a fire safety and evacuation plan with required elements, failed to provide required employee and resident training on fire safety and evacuation, and failed to conduct required evacuation drills. This had the potential to affect all staff, residents, 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 ensure new signed residency agreement contracts were on file for Assisted Living Licensure for 5 of 9 residents (R1, R6, R7, R9, R13) with resident agreement contracts reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure new signed residency agreement contracts were on file for Assisted Living Licensure for 5 of 9 residents (R1, R6, R7, R9, R13) with resident agreement contracts reviewed. [...]”

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 designate a resident representative and designated the facility registered nurse (RN)-A as the emergency contact for 4 of 9 residents (R2, R3, R5, R14)

MDH’s finding, as written: “Based on interview and record review, the licensee failed to designate a resident representative and designated the facility registered nurse (RN)-A as the emergency contact for 4 of 9 residents (R2, R3, R5, R14) with resident agreement contracts reviewed. [...]”

Rule cited: “(a) Before or at the time of execution of an assisted living contract, an assisted living facility must offer the resident the opportunity to identify a designated representative in writing in the contract and must provide the following verbatim notice on a [...]”

Summary: MDH found the licensee included a waiver of liability for the health and safety or personal property of a resident and included a provision implying a lesser standard of care or responsibility than required by law for 4 of 4 residents (R2, R3, R5, R14) with contracts reviewed.

MDH’s finding, as written: “Based on interview and document review, the licensee included a waiver of liability for the health and safety or personal property of a resident and included a provision implying a lesser standard of care or responsibility than required by law for 4 of 4 residents (R2, R3, R5, R14) with contracts reviewed. [...]”

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 four of four employees, unlicensed personnel (ULP)-D, ULP-E. ULP-F, and ULP-G, completed training and competency evaluations in all required training topics.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure four of four employees, unlicensed personnel (ULP)-D, ULP-E. ULP-F, and ULP-G, completed training and competency evaluations in all required training topics. This had the potential to affect all residents receiving services. [...]”

Rule cited: “(b) Unlicensed personnel performing delegated nursing tasks in an assisted living facility must: (1) have successfully completed training and demonstrated competency by successfully completing a written or oral test of the topics in section 144G.61, [...]”

Summary: MDH found the licensee failed to ensure a registered nurse (RN) conducted training and competency evaluations for four of four unlicensed personnel (ULP)-D, ULP-E, ULP-F, and ULP-G, who performed delegated tasks.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure a registered nurse (RN) conducted training and competency evaluations for four of four unlicensed personnel (ULP)-D, ULP-E, ULP-F, and ULP-G, who performed delegated tasks. This had the potential to affect all residents receiving services. [...]”

Rule cited: “(b) When the registered nurse or licensed health professional delegates tasks to unlicensed personnel, that person must ensure that prior to the delegation the unlicensed personnel is trained in the proper methods to perform the tasks or procedures for each [...]”

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 assisted living services for four of four unlicensed personnel, (ULP)-D, ULP-E, ULP-F, and ULP-G, who performed delegated tasks.

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 assisted living services for four of four unlicensed personnel, (ULP)-D, ULP-E, ULP-F, and ULP-G, who performed delegated tasks. This had the potential to affect all residents receiving services. [...]”

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 orientation to assisted living licensing requirements and regulations was provided for five of five employees, registered nurse (RN)-A, unlicensed personnel (ULP)-D, ULP-E, ULP-F, and ULP-G, with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure orientation to assisted living licensing requirements and regulations was provided for five of five employees, registered nurse (RN)-A, unlicensed personnel (ULP)-D, ULP-E, ULP-F, and ULP-G, with records reviewed. This had the potential to affect all residents receiving services. [...]”

Rule cited: “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 staff providing assisted living services were oriented specifically to each individual resident and the services to be provided to individual residents for four of four employees (unlicensed personnel) ULP-D, ULP-E, ULP-F, and ULP-G with employee records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure staff providing assisted living services were oriented specifically to each individual resident and the services to be provided to individual residents for four of four employees (unlicensed personnel) ULP-D, ULP-E, ULP-F, and ULP-G with employee records reviewed. This had the potential to affect all residents receiving services. [...]”

Rule cited: “Staff providing assisted living services must be oriented specifically to each individual resident and the services to be provided. This orientation may be provided in person, orally, in writing, or electronically.”

Summary: MDH found the licensee failed to ensure employees received at least eight hours of annual training for each 12 months of employment for four of four employees, registered nurse (RN)-A and unlicensed personnel (ULP)-E, ULP-F, and ULP-G with employee records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received at least eight hours of annual training for each 12 months of employment for four of four employees, registered nurse (RN)-A and unlicensed personnel (ULP)-E, ULP-F, and ULP-G with employee records reviewed. This had the potential to affect all residents receiving services. [...]”

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 five of five employees, registered nurse (RN)-A, unlicensed personnel (ULP)-D, ULP-D, ULP-F and ULP-G received the required amount of dementia care training in the required time frames.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure five of five employees, registered nurse (RN)-A, unlicensed personnel (ULP)-D, ULP-D, ULP-F and ULP-G received the required amount of dementia care training in the required time frames. This had the potential to affect all residents. [...]”

Rule cited: “(3) for assisted living facilities with dementia care, direct-care employees must have completed at least eight hours of initial training on topics specified under paragraph (b) within 80 working hours of the employment start date. [...]”

Summary: MDH found the licensee failed to provide documented initial assessments for 9 of 9 residents (R1, R2, R3, R5, R6, R7, R9, R13, R14) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide documented initial assessments for 9 of 9 residents (R1, R2, R3, R5, R6, R7, R9, R13, R14) with records reviewed. [...]”

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

Summary: MDH found the licensee failed to provide documented 14-day and 90-day assessments for 9 of 9 residents (R1, R2, R3, R5, R6, R7, R9, R13, R14) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide documented 14-day and 90-day assessments for 9 of 9 residents (R1, R2, R3, R5, R6, R7, R9, R13, R14) 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 9 of 9 residents (R1, R2, R5, R6, R7, R9, R13, R14) had signed service plans on file.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure 9 of 9 residents (R1, R2, R5, R6, R7, R9, R13, R14) had signed service plans on file. 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) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large portion or [...]”

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 all required content for 15 of 18 residents (R1, R2, R3, R4, R5, R6, R7, R8, R10, R11, R14, R15, R16, R17, R18) and failed to provide service plans for 3 of 18 residents (R9, R12, R13) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the service plan included all required content for 15 of 18 residents (R1, R2, R3, R4, R5, R6, R7, R8, R10, R11, R14, R15, R16, R17, R18) and failed to provide service plans for 3 of 18 residents (R9, R12, R13) 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 provide documentation of individualized medication management assessment including all required areas for 8 of 8 residents (R1, R5, R6, R7, R8, R9, R13, R14) receiving medication management services with records reviewed.

MDH’s finding, as written: “Based on interview and document review, the licensee failed to provide documentation of individualized medication management assessment including all required areas for 8 of 8 residents (R1, R5, R6, R7, R8, R9, R13, R14) receiving 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 complete individualized medication management plans including all required areas for 8 of 8 residents (R1, R2, R5, R6, R7, R9, R13, R14) with records reviewed.

MDH’s finding, as written: “Based on interview and document review, the licensee failed to complete individualized medication management plans including all required areas for 8 of 8 residents (R1, R2, R5, R6, R7, R9, R13, R14) 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 one unlicensed personnel (ULP)-E demonstrated competency for administering medications.

MDH’s finding, as written: “Based on interview, observation, and record review, the licensee failed to ensure one unlicensed personnel (ULP)-E demonstrated competency for administering medications. This had the potential to affect all residents receiving services. [...]”

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 unlicensed personnel (ULP) pre-set up medications in medication cups for three of eighteen residents (R13, R16, R17) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee unlicensed personnel (ULP) pre-set up medications in medication cups for three of eighteen residents (R13, R16, R17) with records reviewed. Medications are required to be set up by a registered nurse (RN) or pharmacist. This was a widespread practice with ULP staff that had the potential to affect all residents receiving medications. [...]”

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 signed physician orders were on file for 11 of 11 residents (R1, R2, R3, R5, R6, R7, R9, R13, R14, R15, R16) with records reviewed.

MDH’s finding, as written: “Based on interview and document review, the licensee failed to ensure signed physician orders were on file for 11 of 11 residents (R1, R2, R3, R5, R6, R7, R9, R13, R14, R15, R16) with records reviewed. [...]”

Rule cited: “Prescriptions must be renewed at least every 12 months or more frequently as indicated by the assessment in subdivision 2. Prescriptions for controlled substances must comply with chapter 152.”

Summary: MDH found the licensee failed to ensure multi-use medications were labeled with open dates for 1 of 18 residents (R8) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure multi-use medications were labeled with open dates for 1 of 18 residents (R8) with records reviewed. [...]”

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: “Based on interview and record review the licensee failed to complete a medication disposition form for three of three discharged residents (R19, R20, R21) with records reviewed. [...]”

Rule cited: “(a) Any current medications being managed by the assisted living facility must be provided to the resident when the resident's service plan ends or medication management services are no longer part of the service plan. [...]”

Summary: MDH found the licensee failed to develop and

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 controlled substances defined in Minnesota Rules part 6800.4220. This had the potential to affect all residents receiving services. [...]”

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 ensure unlicensed personnel were trained and demonstrated competency in treatments to a registered nurse (RN) for one of one unlicensed personnel (ULP-E) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure unlicensed personnel were trained and demonstrated competency in treatments to a registered nurse (RN) for one of one unlicensed personnel (ULP-E) with records reviewed. [...]”

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 provide a hazard vulnerability or safety risk assessment that included hazards identified on and around the property.

MDH’s finding, as written: “Based on document review and interview, the licensee failed to provide a hazard vulnerability or safety risk assessment that included hazards identified on and around the property. Mitigation of property hazards to protect residents from harm was not included. This had the potential to directly affect all residents and staff. [...]”

Rule cited: “An assisted living facility with dementia care that has a secured dementia care unit must meet the requirements of section 144G.45 and the following additional requirements: (1) a hazard vulnerability assessment or safety risk must be performed on and around [...]”

Summary: MDH found the licensee failed to develop and implement all required policies and procedures related to dementia care.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and implement all required policies and procedures related to dementia care. This had the potential to affect all residents receiving services. [...]”

Rule cited: “(a) In addition to the policies and procedures required in the licensing of all facilities, the assisted living facility with dementia care licensee must develop and implement policies and procedures that address the: (1) philosophy of how services are [...]”

Summary: MDH found the licensee failed to ensure staff working in the dementia care unit were trained in person-centered care approach for three of three unlicensed personnel (ULP)-E, ULP-F, and

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

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 activity evaluations including all six (6) required areas and written individualized activity plans based on the evaluations were completed for 2 of 2 residents (R5, R6) residing in the memory care unit with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure activity evaluations including all six (6) required areas and written individualized activity plans based on the evaluations were completed for 2 of 2 residents (R5, R6) residing in the memory care unit with records reviewed. [...]”

Rule cited: “(b) Each resident must be evaluated for activities according to the licensing rules of the facility. [...]”

Summary: MDH found the licensee failed to provide in written or electronic form to residents, families, or other persons who request it, an accurate description of the dementia care training program with the required content with records reviewed.

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, an accurate description of the dementia care training program with the required content with records reviewed. This affected all residents. [...]”

Rule cited: “An assisted living facility with dementia care shall make available in written or electronic form, to residents and families or other persons who request it, a description of the training program and related training it provides, including the categories of [...]”

Summary: MDH found the licensee failed to demonstrate it provided written notice to the residents or representatives of a change of ownership within seven calendar days after the licensee received a new license in 11 of 11 residents (R1, R2, R3, R5, R6, R7, R9, R13,

MDH’s finding, as written: “Based on interview and record review, the licensee failed to demonstrate it provided written notice to the residents or representatives of a change of ownership within seven calendar days after the licensee received a new license in 11 of 11 residents (R1, R2, R3, R5, R6, R7, R9, R13, R14, R15, R16) with records reviewed. [...]”

Rule cited: “(a) A facility must provide written notice to the resident, legal representative, or designated representative of a change of ownership within seven calendar days after the facility receives a new license. [...]”

Summary: MDH found the licensee included within the residency agreement contract language which limited the rights of 6 of 6 residents (R1, R2, R3, R5, R6, R14) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee included within the residency agreement contract language which limited the rights of 6 of 6 residents (R1, R2, R3, R5, R6, R14) with records reviewed. [...]”

Rule cited: “The rights established under this section for the benefit of residents do not limit any other rights available under law. [...]”