Aspen Grove Assisted Living

Summary: MDH found the licensee failed to ensure infection control standards were followed for one of three unlicensed personnel (ULP)-G) providing personal cares.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure infection control standards were followed for one of three unlicensed personnel (ULP)-G) providing personal cares. In addition, the licensee failed to establish and maintain an effective infection control program that complies with accepted health care, medical and nursing standards for infection control related to COVID-19. This had the potential to affect all 29 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 post required information related to the licensee's grievance procedure, contact information for the Office of Ombudsman for Long-Term Care and Mental Health and Developmental Disabilities, and information for reporting suspected maltreatment to the Minnesota Adult Abuse Reporting Center (MAARC).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to post required information related to the licensee's grievance procedure, contact information for the Office of Ombudsman for Long-Term Care and Mental Health and Developmental Disabilities, and information for reporting suspected maltreatment to the Minnesota Adult Abuse Reporting Center (MAARC). This had the potential to affect all 29 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 ensure development of an individual abuse prevention plan with the required content for three of three residents (R1, R2, R3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure development of an individual abuse prevention plan with the required content for three of three residents (R1, R2, R3) 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 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 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 impact all 29 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 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 29 residents receiving services under the assisted living with dementia care 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 [...]”

MDH’s finding, as written: “Based on observation and interview, a smoke alarm in a resident room had been compromised. In addition, the facility failed to provide two smoke alarms in the hallways. [...]”

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) [...]”

MDH’s finding, as written: “Based on observation and interview, fire extinguishers were not being maintained. This had the potential to directly affect all residents and staff. This practice resulted in a level two violation (a violation that did not harm a client's health or safety but had the potential to have harmed a client'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: “(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 facility was not being maintained in a continuous state of good repair.

MDH’s finding, as written: “Based on observation and interview, the facility was not being maintained in a continuous state of good repair. This practice resulted in a level two violation (a violation that did not harm a client's health or safety but had the potential to have harmed a client'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 clients are affected or one or a limited number of staff are involved or the [...]”

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 facility failed to provide the required documentation on fire safety and evacuation plans, as well as required evacuation drills.

MDH’s finding, as written: “Based on interview and record review, the facility failed to provide the required documentation on fire safety and evacuation plans, as well as required evacuation drills. In addition, the facility failed to provide documentation on staff training and training plan frequency related to evacuation. This had the potential to directly 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 contract with the required content to provided assisted living services for three of three residents (R1, R2, R3) with records reviewed.

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 to provided assisted living services for three of three residents (R1, R2, R3) with records reviewed. This has the potential to affect all residents. [...]”

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 opportunity to identify a designated representative for three of three residents (R1, R2 and R3) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to offer the opportunity to identify a designated representative for three of three residents (R1, R2 and R3) with records reviewed. This has the potential to affect all residents. [...]”

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 provide staff orientation to assisted living licensing requirements and regulations for three of three employees (RN-B, ULP-C, and ULP-G) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to provide staff orientation to assisted living licensing requirements and regulations for three of three employees (RN-B, ULP-C, and ULP-G) with records reviewed. This has the potential to affect all residents. This has the potential to affect all residents. [...]”

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 employees received the required amount of dementia care training in the required time frame for one of three employees (RN-B) records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure employees received the required amount of dementia care training in the required time frame for one of three employees (RN-B) 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 provide in written or electronic form to residents, families, or other persons who request it, a description of the dementia care training program, the categories of employees trained, the frequency of training and the basic topics covered.

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, a description of the dementia care training program, the categories of employees trained, the frequency of training and the basic topics covered. [...]”

Rule cited: “(5) new employees may satisfy the initial training requirements by producing written proof of previously completed required training within the past 18 months. [...]”

Summary: MDH found the licensee failed to ensure a Registered Nurse (RN) conducted an initial assessment for one of one resident (R2) as required with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure a Registered Nurse (RN) conducted an initial assessment for one of one resident (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 using the uniform assessment tool on day 90 for four of four residents (R3, R4, R8, and R1) 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 using the uniform assessment tool on day 90 for four of four residents (R3, R4, R8, and R1) 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 services plans were revised to reflect the current services provided for three of three residents (R1, R11,

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure services plans were revised to reflect the current services provided for three of three residents (R1, R11, and R13) 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 medications were administered as ordered for two of four residents (R3, R10); and the licensee failed to ensure the steps of the medication administration process was followed for two of three employees (unlicensed personnel/ULP-C, ULP-F) observed administering medications.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were administered as ordered for two of four residents (R3, R10); and the licensee failed to ensure the steps of the medication administration process was followed for two of three employees (unlicensed personnel/ULP-C, ULP-F) observed administering medications. [...]”

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

Summary: MDH found the licensee failed to ensure documentation of medication setup included all the required content for one of one resident (R4) with records reviewed

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure documentation of medication setup included all the required content for one of one resident (R4) 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 [...]”

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.”

MDH’s finding, as written: “Surveyor: Chenze, Jessica Based on interview and record review, the licensee failed to ensure treatments or therapies were administered as prescribed, and to document the reason they were not provided to meet the resident's needs with blood glucose monitoring managed by the provider for one of one resident (R2) 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 the registered nurse (RN) specified, in writing, specific instructions for each resident and documented those instructions in the resident's record for one of one resident receiving blood glucose monitoring (R2) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) specified, in writing, specific instructions for each resident and documented those instructions in the resident's record for one of one resident receiving blood glucose monitoring (R2) 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 ensure treatments or therapies were administered as prescribed, or to document the reason they were not provided to meet the resident's needs for one of one resident (R2) with blood glucose (sugar) monitoring managed by the provider.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure treatments or therapies were administered as prescribed, or to document the reason they were not provided to meet the resident's needs for one of one resident (R2) with blood glucose (sugar) monitoring managed by the provider. [...]”

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

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

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

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 ensue one or more persons were available 24 hours a day, seven days a week who where responsible for responding to requests of residents for assistance.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensue one or more persons were available 24 hours a day, seven days a week who where responsible for responding to requests of residents for assistance. [...]”

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 maintain a dignified dining experience for one of two residents (R12) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to maintain a dignified dining experience for one of two residents (R12) with records reviewed. This practice resulted in a level two violation (a violation that did not harm a client'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: “The licensee of an assisted living facility with dementia care is responsible for the care and housing of the persons with dementia and the provision of person-centered care that promotes each resident's dignity, independence, and comfort. [...]”

Summary: MDH found the licensee failed to ensure policies and procedures for assisted living with dementia care were provided to residents and the residents legal and designated representatives at the time of move-in for one of one resident (R2) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure policies and procedures for assisted living with dementia care were provided to residents and the residents legal and designated representatives at the time of move-in for one of one resident (R2) with records reviewed. [...]”

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 have an evaulation for an activity plan for three of three residents (R1, R2, R3) who resided in the secure dementia care unit.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to have an evaulation for an activity plan for three of three residents (R1, R2, R3) who resided in the secure dementia care unit. [...]”

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 three of three residents (R1, R2, and R3) 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 three of three residents (R1, R2, and R3) 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 ensure two of three residents (R7, R8) was treated with respect and dignity related to privacy.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure two of three residents (R7, R8) was treated with respect and dignity related to privacy. [...]”

Rule cited: “(a) Residents have the right to consideration of their privacy, individuality, and cultural identity as related to their social, religious, and psychological well-being. [...]”

Summary: MDH found the licensee failed to ensure the required notice was posted at the main entry way of the

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the required notice was posted at the main entry way of the facility to display statutory language to disclose electronic monitoring activity. This had the potential to affect all current residents, staff and any visitors of the licensee. [...]”

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 [...]”