Arbor Park Living Center

Summary: MDH found the licensee failed to ensure medications were maintained bearing the original prescription label with legible information including the expiration date for time sensitive medications for two of two residents (R10, R20) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were maintained bearing the original prescription label with legible information including the expiration date for time sensitive medications for two of two residents (R10, R20) 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 [...]”

Summary: MDH found the licensee failed to ensure there were current treatment and therapy orders that included the frequency, duration, and other required information needed for one of one resident (R23) receiving oxygen with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure there were current treatment and therapy orders that included the frequency, duration, and other required information needed for one of one resident (R23) receiving oxygen with records reviewed. [...]”

Rule cited: “There must be an up-to-date written or electronically recorded order from an authorized prescriber for all treatments and therapies. [...]”

Summary: MDH found the licensee failed to provide care and services according to acceptable health care, medical, or nursing standards of one of one resident (R23) with bedrails who lacked a bed rail assessment and an explanation of risks and benefits of the use of 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 of one of one resident (R23) with bedrails who lacked a bed rail assessment and an explanation of risks and benefits of the use of bed rails. This resulted in an immediate order on April 5, 2022, at 2:03 p.m. In addition, the licensee failed to ensure the safe storage of oxygen for one of one resident (R23) with records reviewed. [...]”

Rule cited: “(a) Residents have the right to care and assisted living services that are appropriate based on the resident's needs and according to an up-to-date service plan subject to accepted health care standards.”

Summary: MDH found the licensee failed to obtain consent for electronic monitoring for one of one resident (R23) who had an electronic monitor device in place.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to obtain consent for electronic monitoring for one of one resident (R23) who had an electronic monitor device in place. [...]”

Rule cited: “Subd. 6.Form requirements. (b) Facilities must make the notification and consent form available to the residents and inform residents of their option to conduct electronic monitoring of their rooms or private living unit.”

Summary: MDH found the licensee failed to complete a two-step TST (tuberculin skin test) or other evidence of tuberculosis (TB) screening such as a blood test for two of three employees (unlicensed personnel (ULP)-H and ULP-F), and the licensee failed to ensure completion of TB education was completed for one of two ULP (ULP-F), with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to complete a two-step TST (tuberculin skin test) or other evidence of tuberculosis (TB) screening such as a blood test for two of three employees (unlicensed personnel (ULP)-H and ULP-F), and the licensee failed to ensure completion of TB education was completed for one of two ULP (ULP-F), with records reviewed. [...]”

Rule cited: “(a) The facility must establish and maintain a comprehensive tuberculosis infection control program according to the most current tuberculosis infection control guidelines issued by the United States Centers for Disease Control and Prevention (CDC), Division [...]”

Summary: MDH found the licensee failed to include the location

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to include the location and number of resident rooms in the fire safety and evacuation plans. This had the potential to affect all residents and staff. [...]”

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 two of four residents (R1 and R19) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop and execute a written assisted living contract with the required content for two of four residents (R1 and R19) with records 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 ensure the assisted living with dementia care contract included all required content for two of two residents (R3 and R4), with

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the assisted living with dementia care contract included all required content for two of two residents (R3 and R4), with records reviewed. This had the potential to affect all 41 residents who received assisted living services. [...]”

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 offer two of four residents (R1, R19) the opportunity to identify a designated representative with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to offer two of four residents (R1, R19) the opportunity to identify a designated representative with records 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 failed to ensure training and competency to delegated tasks to include use of a sit to stand lift for one of one unlicensed personnel (ULP-H).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure training and competency to delegated tasks to include use of a sit to stand lift for one of one unlicensed personnel (ULP-H). In addition, the licensee failed to ensure the registered nurse (RN) provided written instructions in the resident's record for the delegated task provided by the ULP for one of one resident (R19) who utilized a sit to stand lift for transfers with records reviewed. [...]”

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 the registered nurse (RN) completed a comprehensive reassessment not to exceed 90 days for one of four residents (R19) 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 a comprehensive reassessment not to exceed 90 days for one of four residents (R19) 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 three of four residents' (R1, R3, and R19) service plans were developed and implemented with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure three of four residents' (R1, R3, and R19) service plans were developed and implemented 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 all required content for two of two residents (R3 and R4) 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 two of two residents (R3 and R4) with records reviewed. [...]”

Rule cited: “(f) The service plan must include: (1) a description of the services to be provided, the fees for services, and the frequency of each service, according to the resident's current assessment and resident preferences; (2) the identification of staff or [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) conducted a face-to-face

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) conducted a face-to-face medication management assessment to include all required content for one of four residents (R19) with records reviewed. [...]”

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

Summary: MDH found the licensee failed to develop and maintain a current individualized medication management plan to include all required content for two of four residents (R3 and R19) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop and maintain a current individualized medication management plan to include all required content for two of four residents (R3 and R19) 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 documentation of medications administered was maintained for one of four residents (R3) and failed to ensure one of two unlicensed personnel (ULP-H) followed the the steps of the medication administration process while administering medications as required.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure documentation of medications administered was maintained for one of four residents (R3) and failed to ensure one of two unlicensed personnel (ULP-H) followed the the steps of the medication administration process while administering medications as required. [...]”

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 document all required content for medication set up for one of one resident (R7) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to document all required content for medication set up for one of one resident (R7) with records reviewed. This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to cause serious injury, impairment, or death), and was issued at an isolated scope (when one or a limited number of residents are [...]”

Rule cited: “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 obtain current written or electronically recorded prescription orders to include tube feeding administration and flushes for one of one resident (R3) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to obtain current written or electronically recorded prescription orders to include tube feeding administration and flushes for one of one resident (R3) with records reviewed. [...]”

Rule cited: “There must be a current written or electronically recorded prescription as defined in section 151.01, subdivision 16a, for all prescribed medications that the assisted living facility is managing for the resident.”

Summary: MDH found the licensee failed to ensure medications were stored according to manufacturer's instructions for four of four medication refrigerators (Aspen, Building 1, Building 2, and Nurse Office).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure medications were stored according to manufacturer's instructions for four of four medication refrigerators (Aspen, Building 1, Building 2, and Nurse Office). [...]”

Rule cited: “An assisted living facility must store all prescription medications in securely locked and substantially constructed compartments according to the manufacturer's directions and permit only authorized personnel to have access.”

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were maintained bearing the original prescription label with legible information including the expiration date for time sensitive medications for four of four residents (R6, R12, R20, and R23) 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 [...]”

Summary: MDH found the licensee failed to develop and implement a treatment or therapy management plan to include the required content for one of two residents (R1) 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 the required content for one of two residents (R1) with records reviewed. [...]”

Rule cited: “For each resident receiving management of ordered or prescribed treatments or therapy services, the assisted living facility must prepare and include in the service plan a written statement of the treatment or therapy services that will be provided to the [...]”

Summary: MDH found the licensee failed to document treatment

MDH’s finding, as written: “Based on interview and record review, the licensee failed to document treatment administration for one of two residents (R1) reviewed who received treatments. This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to cause serious injury, impairment, or death), and was issued at an isolated scope (when one or a limited number of residents are affected or [...]”

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

Summary: MDH found the licensee failed to ensure the facility was staffed twenty four hours a day, seven days a week in the key pad secured unit (Building 2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the facility was staffed twenty four hours a day, seven days a week in the key pad secured unit (Building 2). This had the potential to affect all residents residing at the facility and resulted in an immediate correction order on January 19, 2022, at 4:50 p.m. [...]”

Rule cited: “An assisted living facility with dementia care providing services in a secured dementia care unit must have an awake person who is physically present in the secured dementia care unit 24 hours per day, seven days per week, who is responsible for responding to [...]”

Summary: MDH found the licensee failed to designate a qualified person to oversee staff training in the care of individuals with dementia.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to designate a qualified person to oversee staff training in the care of individuals with dementia. This had the potential to affect all residents, staff and visitors. [...]”

Rule cited: “Persons providing or overseeing staff training must have experience and knowledge in the care of individuals with dementia, including: (1) two years of work experience related to Alzheimer's disease or other dementias, or in health care, gerontology, or [...]”

Summary: MDH found the licensee failed to have an evaluation for an activity plan for one of four residents (R1) who received services under an assisted living with dementia care license with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to have an evaluation for an activity plan for one of four residents (R1) who received services under an assisted living with dementia care license 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 the care and services were provided according to a suitable and up-to-date plan, and subject to accepted health care and medical, or nursing standards for one of one resident (R19) who utilized a sit to stand lift for transfers with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the care and services were provided according to a suitable and up-to-date plan, and subject to accepted health care and medical, or nursing standards for one of one resident (R19) who utilized a sit to stand lift for transfers with records reviewed. [...]”

Rule cited: “(a) Residents have the right to care and assisted living services that are appropriate based on the resident's needs and according to an up-to-date service plan subject to accepted health care standards.”

Summary: MDH found the licensee failed to timely submit a report to the Minnesota Adult Abuse Reporting Center (MAARC) for one of one resident (R20) with a medication error and for one of one resident (R21) who had an altercation with another resident (R3) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to timely submit a report to the Minnesota Adult Abuse Reporting Center (MAARC) for one of one resident (R20) with a medication error and for one of one resident (R21) who had an altercation with another resident (R3) with records reviewed. [...]”

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

Summary: MDH found the licensee failed to post the required information related to the grievance procedure, as well as information for reporting suspected maltreatment to the Minnesota Adult Abuse Reporting Center (MAARC).

MDH’s finding, as written: “Based on observation and interview, the licensee failed to post the required information related to the grievance procedure, as well as information for reporting suspected maltreatment to the Minnesota Adult Abuse Reporting Center (MAARC). This had the potential to affect all 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 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 clients, 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 to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment and complete a thorough investigation for one of one resident (R2), with record reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment and complete a thorough investigation for one of one resident (R2), with record reviewed. [...]”

Rule cited: “144G.42 Subd. 6. Compliance with requirements for reporting maltreatment of vulnerable adults; abuse prevention plan. (a) The assisted living facility must comply with the requirements for the reporting of maltreatment of vulnerable adults in section 626.557. [...]”

Summary: MDH found the licensee failed to ensure an individual

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure an individual abuse prevention plan was developed to include the required content for four of four residents (R1, R2, R3 and R4) with records reviewed. [...]”

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 post the required content in common areas to include: posting the 911 emergency number in common areas and near telephones provided by the assisted living facility; and posting information and the reporting number for the Minnesota Adult Abuse Reporting Center (MAARC) to report suspected maltreatment of a vulnerable adult under section 626.557.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to post the required content in common areas to include: posting the 911 emergency number in common areas and near telephones provided by the assisted living facility; and posting information and the reporting number for the Minnesota Adult Abuse Reporting Center (MAARC) to report suspected maltreatment of a vulnerable adult under section 626.557. This had the potential to affect all 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 ensure the provider established and maintained a tuberculosis (TB) prevention program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included documentation of a completed TB Facility Risk Assessment,

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the provider established and maintained a tuberculosis (TB) prevention program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included documentation of a completed TB Facility Risk Assessment, screen for active and latent TB for three of four employees (registered nurse (RN)-B, unlicensed personnel (ULP)-F, and ULP-H). [...]”

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 plan with all the required content and failed to post an emergency preparedness plan prominently.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to have a written emergency preparedness plan with all the required content and failed to post an emergency preparedness plan prominently. This had the potential to affect all current 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 documentation of services had been provided as identified in the service plan for four of four residents (R1, R2, R3 and R4) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure documentation of services had been provided as identified in the service plan for four of four residents (R1, R2, R3 and R4) with records 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 facility failed to provide a sufficient number of smoke alarms outside resident sleeping areas in the Birches and Oaks buildings.

MDH’s finding, as written: “Based on observation and interview, the facility failed to provide a sufficient number of smoke alarms outside resident sleeping areas in the Birches and Oaks buildings. This had the potential to directly affect all residents, staff and visitors in those buildings. [...]”

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 facility failed to ensure a smoking shed was maintained in a continuous state of good repair and operation with regard to the health, safety, comfort, and well-being of the residents in accordance with a maintenance and repair program.

MDH’s finding, as written: “Based on observation and interview, the facility failed to ensure a smoking shed was maintained in a continuous state of good repair and operation with regard to the health, safety, comfort, and well-being of the residents in accordance with a maintenance and repair program. This had the potential to 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 and execute a written contract with the required content for

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop and execute a written contract with the required content for four of four residents (R3, R4, R1 and R2) with records 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 offer four of four residents (R3, R4, R1 and R2) the opportunity to identify a designated representative with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to offer four of four residents (R3, R4, R1 and R2) the opportunity to identify a designated representative with records 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 failed to ensure correct authentication with name and title of the person making the entry for one of four employees (unlicensed personnel (ULP)-F) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure correct authentication with name and title of the person making the entry for one of four employees (unlicensed personnel (ULP)-F) with records reviewed. [...]”

Rule cited: “(a) Licensed health professionals and nurses providing services as employees of a licensed facility must possess a current Minnesota license or registration to practice. [...]”

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure orientation to assisted living licensing requirements and regulations was provided for four of four employees (registered nurse (RN)-B, licensed practical nurse (LPN)-C, unlicensed personnel (ULP)-F, and ULP-H) with records reviewed. [...]”

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 four of four employees (registered nurse (RN)-B, licensed practical nurse (LPN)-C, unlicensed personal (ULP)-E and ULP-H) 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 four of four employees (registered nurse (RN)-B, licensed practical nurse (LPN)-C, unlicensed personal (ULP)-E and ULP-H) received the required amount of dementia care training in the required time frame with records reviewed. [...]”

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 ensure the registered nurse (RN) completed a 14 day reassessment for one of one resident (R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) completed a 14 day reassessment for one of one resident (R2). In addition, the licensee failed to ensure the RN completed a reassessment not to exceed 90 days for three of three residents (R1, R3 and R4) 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 four of four residents' (R1, R2, R3 and R4) service plans were developed and implemented with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure four of four residents' (R1, R2, R3 and R4) service plans were developed and implemented 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 registered nurse (RN) conducted a face-to-face medication management assessment to include all required content for four of four residents (R1, R2, R3 and R4) 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 a face-to-face medication management assessment to include all required content for four of four residents (R1, R2, R3 and R4) with records reviewed. [...]”

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

Summary: MDH found the licensee failed to develop and maintain a current individualized medication management record for each resident to include all required content for four for four residents (R1, R2, R3 and R4) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop and maintain a current individualized medication management record for each resident to include all required content for four for four residents (R1, R2, R3 and R4) 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 of one unlicensed personnel (ULP-F) demonstrated competency for administering medication via feeding tube.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure one of one unlicensed personnel (ULP-F) demonstrated competency for administering medication via feeding tube. In addition, the registered nurse (RN) failed to specify, in writing, specific instructions for one of one resident (R3) for administration of medications via feeding tube. [...]”

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 administered according to manufacturer's instructions for one of one resident (R16) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure medications were administered according to manufacturer's instructions for one of one resident (R16) with records reviewed. In addition, the licensee failed to ensure medications were transcribed as prescribed for one of nine residents (R18) with records reviewed. [...]”

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 document all required content for medication set up for one of two residents (R2) reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to document all required content for medication set up for one of two residents (R2) reviewed. This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to cause serious injury, impairment, or death), and was issued at an isolated scope (when one or a limited number of residents are [...]”

Rule cited: “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 the registered nurse (RN) developed written procedures for the unlicensed personnel (ULP) providing medications for residents having unplanned time away when the licensed nurse was not available; and failed to provide complete documentation of medications sent with one of one resident (R1) who had an unplanned time away.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the registered nurse (RN) developed written procedures for the unlicensed personnel (ULP) providing medications for residents having unplanned time away when the licensed nurse was not available; and failed to provide complete documentation of medications sent with one of one resident (R1) who had an unplanned time away. [...]”

Rule cited: “(2) for unplanned time away, when the pharmacy is not able to provide the medications, a licensed nurse or unlicensed personnel shall provide medications in amounts and dosages needed for the length of the anticipated absence, not to exceed seven calendar [...]”

Summary: MDH found the licensee failed to ensure written or electronically recorded prescriptions were obtained for one of nine residents (R3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure written or electronically recorded prescriptions were obtained for one of nine residents (R3) with records reviewed. [...]”

Rule cited: “There must be a current written or electronically recorded prescription as defined in section 151.01, subdivision 16a, for all prescribed medications that the assisted living facility is managing for the resident.”

Summary: MDH found the licensee failed to ensure medications were stored according to manufacturer's instructions for two of two medication refrigerators (Aspen and Oaks).

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

Rule cited: “An assisted living facility must store all prescription medications in securely locked and substantially constructed compartments according to the manufacturer's directions and permit only authorized personnel to have access.”

Summary: MDH found the licensee failed to ensure medications were maintained bearing the original prescription

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure medications were maintained bearing the original prescription label with legible information including the expiration date for time sensitive medications for four of four residents (R9, R10, R16 and R17) 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 [...]”

Summary: MDH found the licensee failed to provide documentation in the resident's record regarding the disposition of medication to include the medication strength, prescription number, quantity, date of disposition, and names of staff and other individuals involved in the disposition for one of one deceased resident (R5) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide documentation in the resident's record regarding the disposition of medication to include the medication strength, prescription number, quantity, date of disposition, and names of staff and other individuals involved in the disposition for one of one deceased resident (R5) 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 follow the procedure for loss and spillage of a controlled substance for one of one resident (R2), who had a controlled substance managed by the facility.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to follow the procedure for loss and spillage of a controlled substance for one of one resident (R2), who had a controlled substance managed by the facility. [...]”

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 and implement a treatment or therapy management plan to include the required content for two of three residents (R1, R3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop and implement a treatment or therapy management plan to include the required content for two of three residents (R1, 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 specific written instructions for each resident were documented in one of one resident's record (R1) who received blood glucose monitoring.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure specific written instructions for each resident were documented in one of one resident's record (R1) who received blood glucose monitoring. [...]”

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 document treatment administration for two of two residents (R1 and R3) reviewed who received treatments.

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

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

Summary: MDH found the licensee failed ensure up-to-date written or electronically recorded orders were

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed ensure up-to-date written or electronically recorded orders were maintained for one of three residents (R3) receiving treatments. [...]”

Rule cited: “There must be an up-to-date written or electronically recorded order from an authorized prescriber for all treatments and therapies. [...]”

Summary: MDH found the facility failed to provide a hazard vulnerability or safety risk assessment for the facility.

MDH’s finding, as written: “Based on observation, interview and record review, the facility failed to provide a hazard vulnerability or safety risk assessment for the facility. This had the potential to affect all dementia care residents, staff and visitors. [...]”

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 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 [...]”

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 designate a qualified person to oversee staff training in the care of individuals with dementia.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to designate a qualified person to oversee staff training in the care of individuals with dementia. This had the potential to affect all residents, staff and visitors. [...]”

Rule cited: “Persons providing or overseeing staff training must have experience and knowledge in the care of individuals with dementia, including: (1) two years of work experience related to Alzheimer's disease or other dementias, or in health care, gerontology, or [...]”

Summary: MDH found the licensee failed to have an evaluation for an activity plan for four of four residents (R1, R2, R3 and R4) who received services under an assisted living with dementia care license.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to have an evaluation for an activity plan for four of four residents (R1, R2, R3 and R4) who received services under an assisted living with dementia care license. [...]”

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 the current Minnesota Bill of Rights for Assisted Living Residents was provided to the resident and a written acknowledgement received for four of four residents (R1, R2, R3 and R4) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the current Minnesota Bill of Rights for Assisted Living Residents was provided to the resident and a written acknowledgement received for four of four residents (R1, R2, R3 and R4) with records reviewed. [...]”

Rule cited: “(a) An assisted living facility must provide the resident a written notice of the rights under section 144G.91 before the initiation of services to that resident. [...]”

Summary: MDH found the licensee failed to post daily staffing information to keep each resident informed about persons who can assist with health care or supportive services being provided.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to post daily staffing information to keep each resident informed about persons who can assist with health care or supportive services being provided. This had the potential to affect all residents, staff and visitors. [...]”

Rule cited: “A facility shall provide each resident with identifying and contact information about the persons who can assist with health care or supportive services being provided. [...]”

Summary: MDH found the licensee failed to provide care and services according the acceptable health care medical or nursing standards of one of one resident (R2) with bedrails and for medication set

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to provide care and services according the acceptable health care medical or nursing standards of one of one resident (R2) with bedrails and for medication set up by unlicesensed personnel for two of two residents (R3, R15) reviewed. In addition, the licensee failed to ensure safe storage of oxygen. [...]”

Rule cited: “(a) Residents have the right to care and assisted living services that are appropriate based on the resident's needs and according to an up-to-date service plan subject to accepted health care standards.”

Summary: MDH found the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment and complete a thorough investigation for one of one resident (R2) with record reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment and complete a thorough investigation for one of one resident (R2) with record reviewed. [...]”

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

Summary: MDH found the licensee failed to post a sign related to electronic monitoring at facility entrances.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to post a sign related to electronic monitoring at facility entrances. This had the potential to affect all residents, staff and visitors. [...]”

Rule cited: “Subd. 8.Notice to visitors. (a) A facility must post a sign at each facility entrance accessible to visitors that states: "Electronic monitoring devices, including security cameras and audio devices, may be present to record persons and activities." (b) The [...]”