Bay Harbor Senior Living of la

Summary: MDH found the licensee failed to review and update an all-hazards risk assessment emergency

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to review and update an all-hazards risk assessment emergency preparedness program and plan to include Appendix Z required elements and failed to post the plan prominently. This had the potential to affect all 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 maintain facility in compliance with Minnesota State Fire Code under Minnesota Rules Chapter 7511.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain facility in compliance with Minnesota State Fire Code under Minnesota Rules Chapter 7511. This had the potential to affect all residents, staff, and visitors. [...]”

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 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 (R11).

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 (R11). [...]”

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 ensure a licensed practical nurse (LPN), who was providing services as an employee of the licensed facility, had a current Minnesota license or registration to practice, for one of one employee (LPN-B).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a licensed practical nurse (LPN), who was providing services as an employee of the licensed facility, had a current Minnesota license or registration to practice, for one of one employee (LPN-B). This had the potential to affect all residents and staff. This resulted in an immediate correction order issued on September 23, 2025. [...]”

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

Summary: MDH found the licensee failed to ensure training and competency evaluations for the required topics were completed by one of two unlicensed personnel (ULP-J) prior to providing direct cares.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure training and competency evaluations for the required topics were completed by one of two unlicensed personnel (ULP-J) prior to providing direct cares. [...]”

Rule cited: “(a) Unlicensed personnel providing assisted living services must have: (1) successfully completed a training and competency evaluation appropriate to the services provided by the facility and the topics listed in section 144G.61, subdivision 2, paragraph (a); [...]”

Summary: MDH found the licensee failed to ensure competency training and evaluations were completed by one of two unlicensed personnel (ULP-J) prior to providing direct cares.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure competency training and evaluations were completed by one of two unlicensed personnel (ULP-J) prior to providing direct cares. [...]”

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 two of two employees (unlicensed personnel (ULP)-F, ULP-J) completed all training and competency evaluations prior to providing delegated nursing tasks to one of one resident (R4) with a Pure wick urinary system.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure two of two employees (unlicensed personnel (ULP)-F, ULP-J) completed all training and competency evaluations prior to providing delegated nursing tasks to one of one resident (R4) with a Pure wick urinary system. [...]”

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 direct supervision of one of two unlicensed personnel (ULP-J) performing delegated tasks was provided by the registered nurse (RN) within 30

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure direct supervision of one of two unlicensed personnel (ULP-J) performing delegated tasks was provided by the registered nurse (RN) within 30 calendar days after the date on which the individual began working for the licensee. [...]”

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 one of two

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one of two employees (unlicensed personnel (ULP)-J) received orientation to assisted living facility licensing requirements and regulations before providing services. [...]”

Rule cited: “(a) The orientation must contain the following topics: (1) an overview of this chapter; (2) an introduction and review of the facility's policies and procedures related to the provision of assisted living services by the individual staff person; (3) handling [...]”

Summary: MDH found the licensee failed to ensure annual training included all required topics for each 12 months of employment for one of one employee (unlicensed personnel (ULP)-F).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure annual training included all required topics for each 12 months of employment for one of one employee (unlicensed personnel (ULP)-F). [...]”

Rule cited: “(a) All staff that perform direct services must complete at least eight hours of annual training for each 12 months of employment. [...]”

Summary: MDH found the licensee failed to ensure two of two employees (unlicensed personnel (ULP)-F and ULP-J) received the required amount of dementia, mental illness and de-escalation training within the required time frame.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure two of two employees (unlicensed personnel (ULP)-F and ULP-J) received the required amount of dementia, mental illness and de-escalation training within the required time frame. [...]”

Rule cited: “(3) for assisted living facilities with dementia care, direct-care staff 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 reassessment not to exceed 90 days from the previous assessment for three of three residents (R2, R3, R4).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) completed a reassessment not to exceed 90 days from the previous assessment for three of three residents (R2, R3, R4). [...]”

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 the service plan included a signature or other authentication by the resident and the facility to document agreement on the services provided for three of seven residents (R3, R11, R14).

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 provided for three of seven residents (R3, R11, R14). [...]”

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 one of seven residents (R14) who received services.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the service plan included all required content for one of seven residents (R14) who received services. [...]”

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 medications were administered as ordered for two of seven residents (R2, R1), and failed to ensure all medications were transcribed with clear instruction for two of seven residents (R14, R12).

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 seven residents (R2, R1), and failed to ensure all medications were transcribed with clear instruction for two of seven residents (R14, R12). [...]”

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 current written or electronically recorded prescriptions were obtained for all medications the provider managed for three of six residents (R3, R4, R14).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure current written or electronically recorded prescriptions were obtained for all medications the provider managed for three of six residents (R3, R4, R14). [...]”

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 stored medications were not expired for four of 59 residents (R6, R8, R9, R10) receiving medication administration.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure stored medications were not expired for four of 59 residents (R6, R8, R9, R10) receiving medication administration. Additionally, the licensee failed to ensure all medications bore a proper label and included an open date for time sensitive medications. [...]”

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 the registered nurse (RN) specified, in writing, specific instructions and documented those instructions in the resident record for one of one resident (R2) with blood sugar monitoring.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) specified, in writing, specific instructions and documented those instructions in the resident record for one of one resident (R2) with blood sugar 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 ensure policies and procedures required in the licensing of assisted living facilities with dementia care were provided to each resident and the resident's legal and designated representative at the time of move-in for four of four residents (R1, R2, R3, R4).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure policies and procedures required in the licensing of assisted living facilities with dementia care were provided to each resident and the resident's legal and designated representative at the time of move-in for four of four residents (R1, R2, R3, R4). [...]”

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 conduct an individualized written activity evaluation that addressed all six provisions and develop an individualized activity plan for one of two residents (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 conduct an individualized written activity evaluation that addressed all six provisions and develop an individualized activity plan for one of two residents (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 behavioral symptoms were identified and were addressed on the care plan for one of two residents (R4).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure behavioral symptoms were identified and were addressed on the care plan for one of two residents (R4). [...]”

Rule cited: “(e) Behavioral symptoms that negatively impact the resident and others in the assisted living facility with dementia care must be evaluated and included on the service or care plan. [...]”

Summary: MDH found the licensee failed to ensure signage was posted at the main entry of the building of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all residents, staff, and visitors of the licensee.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure signage was posted at the main entry of the building of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all residents, staff, and visitors of the licensee. [...]”

Rule cited: “(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 facility is responsible for [...]”