Axis Home Health Care

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

Summary: MDH found the licensee failed to ensure the physical environment of the facility was maintained in compliance with the requirements

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

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

Summary: MDH found the licensee failed to provide a written notice with required content for an emergency relocation and failed to notify the Office of Ombudsman for Long-Term Care of the emergency relocation for one of one resident (R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a written notice with required content for an emergency relocation and failed to notify the Office of Ombudsman for Long-Term Care of the emergency relocation for one of one resident (R2). [...]”

Rule cited: “(a) A facility may remove a resident from the facility in an emergency if necessary due to a resident's urgent medical needs or an imminent risk the resident poses to the health or safety of another facility resident or facility staff member. [...]”

Summary: MDH found the licensee failed to provide staff orientation to assisted living licensing requirements and regulations for one of two employees (clinical nurse supervisor (CNS) -B).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide staff orientation to assisted living licensing requirements and regulations for one of two employees (clinical nurse supervisor (CNS) -B). This had the potential to affect all residents. [...]”

Rule cited: “(a) All staff providing and supervising direct services must complete an orientation to assisted living facility licensing requirements and regulations before providing assisted living services to residents. [...]”

Summary: MDH found the licensee failed to ensure staff received dementia, mental illness, and de-escalation training in the required areas for one of two employees (clinical nurse supervisor (CNS) -B).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure staff received dementia, mental illness, and de-escalation training in the required areas for one of two employees (clinical nurse supervisor (CNS) -B). [...]”

Rule cited: “All direct care staff and supervisors providing direct services must demonstrate an understanding of the training specified in section 144G.64.”

Summary: MDH found the licensee failed to ensure employees received eight hours of initial dementia care training within the first 120 hours worked for one of two employees (clinical nurse supervisor (CNS) -B).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received eight hours of initial dementia care training within the first 120 hours worked for one of two employees (clinical nurse supervisor (CNS) -B). This had the potential to affect all residents and staff. [...]”

Rule cited: “(a) All assisted living facilities must meet the following dementia care, mental illness, and de-escalation training requirements: (1) supervisors of direct-care staff must have at least eight hours of initial training on dementia topics specified under [...]”

Summary: MDH found the licensee failed to ensure a registered nurse (RN) conducted a change of condition assessment for one of two residents (R2).

MDH’s finding, as written: “Based on interview, and record review, the licensee failed to ensure a registered nurse (RN) conducted a change of condition assessment for one of two residents (R2). This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large [...]”

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

Summary: MDH found the licensee failed to develop and maintain a current individualized medication management record to include all required content for two of two residents (R2).

MDH’s finding, as written: “Based on interview, and record review, the licensee failed to develop and maintain a current individualized medication management record to include all required content for two of two residents (R2). [...]”

Rule cited: “(a) For each resident receiving medication management services, a registered nurse, advanced practice registered nurse, or qualified staff delegated the task by a registered nurse must prepare and include in the service plan a written statement of the [...]”

Summary: MDH found the licensee failed to ensure medication administration was documented for two of two residents (R1, R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure medication administration was documented for two of two residents (R1, R2). This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large portion or all the [...]”

Rule cited: “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

MDH’s finding, as written: “Based on interview, and record review, the licensee failed to ensure documentation of medication setup included all the required content for two of two residents (R1, R2). [...]”

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

MDH’s finding, as written: “Based on interview, and record review, the licensee failed to ensure the registered nurse (RN) developed training and competencies for unlicensed personnel (ULP) providing medications to residents for unplanned time away from home when the licensed nurse was not available for two of two employees (ULP-D and ULP-E). [...]”

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 the refrigerator storing medications maintained an acceptable temperature and medications were stored according to manufacturer's recommended temperature.

MDH’s finding, as written: “Based on interview, and record review, the licensee failed to ensure the refrigerator storing medications maintained an acceptable temperature and medications were stored according to manufacturer's recommended temperature. In addition, the licensee failed to ensure prescription medications were securely locked in a substantially constructed compartment and permitted only authorized personnel to have access. This had the potential to affect all residents in the facility. [...]”

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 interview, and record review the licensee failed to ensure up-to-date written or electronically recorded orders were maintained for one of two residents (R1) 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 licensee failed to ensure the physical environment of the facility was maintained in compliance with the requirements of Minnesota Statute 144G.

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

Rule cited: “Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and:”

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

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

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

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

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

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

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

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

Summary: MDH found the licensee failed to provide a written notice with required content for an emergency relocation and failed to notify the Office of Ombudsman for Long-Term Care of the emergency relocation for one of one resident (R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a written notice with required content for an emergency relocation and failed to notify the Office of Ombudsman for Long-Term Care of the emergency relocation for one of one resident (R2). [...]”

Rule cited: “(a) A facility may remove a resident from the facility in an emergency if necessary due to a resident's urgent medical needs or an imminent risk the resident poses to the health or safety of another facility resident or facility staff member. [...]”

Summary: MDH found the licensee failed to provide staff orientation to assisted living licensing requirements and regulations for one of two employees (clinical nurse supervisor (CNS) -B).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide staff orientation to assisted living licensing requirements and regulations for one of two employees (clinical nurse supervisor (CNS) -B). This had the potential to affect all residents. [...]”

Rule cited: “(a) All staff providing and supervising direct services must complete an orientation to assisted living facility licensing requirements and regulations before providing assisted living services to residents. [...]”

Summary: MDH found the licensee failed to ensure staff received dementia, mental illness, and de-escalation training in the required areas for one of two employees (clinical nurse supervisor (CNS) -B).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure staff received dementia, mental illness, and de-escalation training in the required areas for one of two employees (clinical nurse supervisor (CNS) -B). [...]”

Rule cited: “All direct care staff and supervisors providing direct services must demonstrate an understanding of the training specified in section 144G.64.”

Summary: MDH found the licensee failed to ensure employees received eight hours of initial dementia care training within the first 120 hours worked for one of two employees (clinical nurse supervisor (CNS) -B).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received eight hours of initial dementia care training within the first 120 hours worked for one of two employees (clinical nurse supervisor (CNS) -B). This had the potential to affect all residents and staff. [...]”

Rule cited: “(a) All assisted living facilities must meet the following dementia care, mental illness, and de-escalation training requirements: (1) supervisors of direct-care staff must have at least eight hours of initial training on dementia topics specified under [...]”

Summary: MDH found the licensee failed to ensure a registered nurse (RN) conducted a change of condition assessment for one of two residents (R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a registered nurse (RN) conducted a change of condition assessment for one of two residents (R2). [...]”

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

Summary: MDH found the licensee failed to ensure a service plan was developed for one of two residents (R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a service plan was developed for one of two residents (R2). This practice resulted in a level two violation (a violation that has no potential to cause more than a minimal impact on the resident and does not affect health or safety) and was issued at an isolated scope (when one or a limited number of residents are affected or one or a limited number of staff are involved, or the situation has occurred only [...]”

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 develop and maintain a current individualized medication management record to include all required content for two of two residents (R2).

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 to include all required content for two of two residents (R2). [...]”

Rule cited: “(a) For each resident receiving medication management services, a registered nurse, advanced practice registered nurse, or qualified staff delegated the task by a registered nurse must prepare and include in the service plan a written statement of the [...]”

Summary: MDH found the licensee failed to ensure medication administration was documented for two of two residents (R1, R2).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure medication administration was documented for two of two residents (R1, R2). This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large portion or [...]”

Rule cited: “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 two of two residents (R1, R2).

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 two of two residents (R1, R2). [...]”

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 training and competencies for unlicensed personnel (ULP) providing medications to residents for unplanned time away from home when the licensed nurse was not available for two of two employees (ULP-D and ULP-E).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) developed training and competencies for unlicensed personnel (ULP) providing medications to residents for unplanned time away from home when the licensed nurse was not available for two of two employees (ULP-D and ULP-E). [...]”

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 the refrigerator storing medications maintained an acceptable temperature and medications were stored according to manufacturer's recommended temperature.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the refrigerator storing medications maintained an acceptable temperature and medications were stored according to manufacturer's recommended temperature. In addition, the licensee failed to ensure prescription medications were securely locked in a substantially constructed compartment and permitted only authorized personnel to have access. This had the potential to affect all residents in the facility. [...]”

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 up-to-date written or electronically recorded orders were maintained for one of two residents (R1) 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. [...]”