Armstrong Homes

Summary: MDH found the licensee failed to develop and implement a staffing plan to determine staffing levels to meet the needs of all residents.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and implement a staffing plan to determine staffing levels to meet the needs of all residents. This had the potential to affect all residents, staff and visitors. [...]”

Rule cited: “(11) develop and implement a staffing plan for determining its staffing level that: (i) includes an evaluation, to be conducted at least twice a year, of the appropriateness of staffing levels in the facility; (ii) ensures sufficient staffing at all times to [...]”

Summary: MDH found the licensee failed to ensure food was prepared 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 according to the Minnesota Food Code. This had the potential to affect all residents. [...]”

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 [...]”

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to have a daily program of social and recreational activities based on individual and group interests, physical, mental, and psychosocial needs, that create opportunities for active participation in the community at large. This had the potential to affect all residents who received services. [...]”

Rule cited: “(ii) weekly housekeeping; (iii) weekly laundry service; (iv) upon the request of the resident, provide direct or reasonable assistance with arranging for transportation to medical and social services appointments, shopping, and other recreation, and provide [...]”

MDH’s finding, as written: “Based on observation, interview and record review the licensee failed to establish and maintain an effective infection control program to comply with accepted health care, medical, and nursing standards for infection control related to current recommendations for Coronavirus (COVID-19). This practice had the potential to affect all of the licensee's residents, staff and visitors. [...]”

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 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 facility failed to update an individual abuse prevention plan (IAPP) to include the person's risk of abusing others and identify specific measures to be taken to minimize the risk of abuse to other vulnerable adults for one of two residents (R1) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the facility failed to update an individual abuse prevention plan (IAPP) to include the person's risk of abusing others and identify specific measures to be taken to minimize the risk of abuse to other vulnerable adults for one of two residents (R1) 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 911 emergency number in common areas and near telephones provided by the assisted living facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to post the 911 emergency number in common areas and near telephones provided by the assisted living facility. 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 employee records included all required content for one of one employee (unlicensed personnel (ULP)-B) with employee record reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure employee records included all required content for one of one employee (unlicensed personnel (ULP)-B) with employee record reviewed. [...]”

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

Summary: MDH found the licensee failed to establish and maintain a tuberculosis (TB) prevention program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included documentation of a completed TB Facility Risk Assessment and the licensee failed to ensure TB screening and training was completed for one of two employees (unlicensed personnel (ULP)-B) with employee records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to establish and maintain a tuberculosis (TB) prevention program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included documentation of a completed TB Facility Risk Assessment and the licensee failed to ensure TB screening and training was completed for one of two employees (unlicensed personnel (ULP)-B) with employee 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 have a written emergency

MDH’s finding, as written: “Based on interview and record review, the licensee failed to have a written emergency disaster preparedness plan with all required content. This had the potential to affect the licensee's two 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 smoke alarms are interconnected so that actuation of one alarm causes all alarms in the dwelling to actuate as required.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure smoke alarms are interconnected so that actuation of one alarm causes all alarms in the dwelling to actuate as required. This had the potential to directly affect all residents, staff, and visitors. [...]”

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 ensure the installation and maintenance of portable fire extinguishers at the facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure the installation and maintenance of portable fire extinguishers at the facility. This had the potential to directly affect all residents, staff, and visitors. [...]”

Rule cited: “(2) install and maintain portable fire extinguishers in accordance with the State Fire Code; (3) install portable fire extinguishers having a minimum 2-A:10-B:C rating within Group R-3 occupancies, as defined by the State Fire Code, located so that the travel [...]”

Summary: MDH found the licensee failed to maintain the facility's physical environment in a continuous state of good repair and operation regarding the health, safety, and well-being of the residents.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the facility's physical environment in a continuous state of good repair and operation regarding the health, safety, and well-being of the residents. This had the potential to directly affect all residents, staff, and visitors. [...]”

Rule cited: “(4) keep the physical environment, including walls, floors, ceiling, all furnishings, grounds, systems, and equipment in a continuous state of good repair and operation with regard to the health, safety, comfort, and well-being of the residents in accordance [...]”

Summary: MDH found the licensee failed to develop and

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop and maintain fire safety and evacuation plans, failed to provide required training to residents and employees for fire safety and evacuation, and failed to conduct required employee evacuation drills. This had the potential to affect all current residents, staff, and visitors to the facility. [...]”

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

Summary: MDH found the licensee failed to execute a written contract with the required content for one of two residents (R1) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to execute a written contract with the required content for one of two residents (R1) 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 the resident the opportunity to identify a designated representative in writing with the required statutory language for one of two residents (R2) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to offer the resident the opportunity to identify a designated representative in writing with the required statutory language for one of two residents (R2) 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 the assisted living contract did not include language waiving the facility's liability for health, safety, or personal property of a resident for one of two residents (R2) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the assisted living contract did not include language waiving the facility's liability for health, safety, or personal property of a resident for one of two residents (R2) with records reviewed. [...]”

Rule cited: “The contract must not include a waiver of facility liability for the health and safety or personal property of a resident. [...]”

MDH’s finding, as written: “Based on observation, interview and record review the licensee failed to ensure the unlicensed personnel performing delegated nursing task in the assisted living facility completed training and demonstrated competency in all required areas for one of one employee (unlicensed personnel (ULP)-B) with employee record reviewed. [...]”

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)-A) was readily available for consultation to the staff performing delegated nursing tasks and services.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a registered nurse ((RN)-A) was readily available for consultation to the staff performing delegated nursing tasks and services. This had the potential to affect all residents and staff of the facility. The licensee hired RN-A to perform all nursing tasks. [...]”

Rule cited: “(a) Assisted living facilities must have a registered nurse available for consultation by staff performing delegated nursing tasks and must have an appropriate licensed health professional available if performing other delegated services such as therapies.”

Summary: MDH found the licensee failed to ensure a registered nurse ((RN)-A) conducted supervision of unlicensed staff as required for one of one unlicensed personnel ((ULP)-B) with record reviewed.

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

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

Summary: MDH found the licensee failed to ensure staff providing services completed an orientation to assisted living facility licensing requirements and regulations before providing services for one of one unlicensed personnel ((ULP)-B) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure staff providing services completed an orientation to assisted living facility licensing requirements and regulations before providing services for one of one unlicensed personnel ((ULP)-B) with record 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 direct care staff received the required amount of dementia care training in the required time frame for one of one employee (unlicensed personnel (ULP)-B) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure direct care staff received the required amount of dementia care training in the required time frame for one of one employee (unlicensed personnel (ULP)-B) with record reviewed. [...]”

Rule cited: “(a) All assisted living facilities must meet the following training requirements: (1) supervisors of direct-care staff must have at least eight hours of initial training on topics specified under paragraph (b) within 120 working hours of the employment start [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) completed an initial comprehensive nursing assessment prior to signing the assisted living contract/providing services for two of two residents (R1, R2) as required, with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) completed an initial comprehensive nursing assessment prior to signing the assisted living contract/providing services for two of two residents (R1, R2) as required, 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 ensure the registered nurse (RN) completed a comprehensive reassessment no later than 14 days after services initiation to two of two residents (R1, R2) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) completed a comprehensive reassessment no later than 14 days after services initiation to two of two residents (R1, R2) 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 the service plan included a signature or other authentication by the resident and the facility to document agreement on the services to be provided to one of two residents (R1) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the service plan included a signature or other authentication by the resident and the facility to document agreement on the services to be provided to one of two residents (R1) with records reviewed. [...]”

Rule cited: “(a) No later than 14 calendar days after the date that services are first provided, an assisted living facility shall finalize a current written service plan. [...]”

Summary: MDH found the licensee failed to ensure the service plan included the required content for two of two residents (R1, R2) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the service plan included the required content for two of two residents (R1, R2) 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 a current written or electronically recorded prescription was obtained for all medications the provider managed to two of two residents (R1, R2) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure a current written or electronically recorded prescription was obtained for all medications the provider managed to two of two residents (R1, R2) 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.”

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 name, medication strength, prescription number, quantity, and to whom the medications were given for one of one discharged resident (R3) with record 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. [...]”