Belevo Health Services

Summary: MDH found the licensee failed to have a daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs for two of two residents (R1, R2) with records reviewed.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to have a daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs for two of two residents (R1, R2) with records reviewed. [...]”

Rule cited: “(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 the name of or other identifying information about the [...]”

Summary: MDH found the licensee failed to ensure an Individual Abuse Prevention Plan (IAPP) was updated after R3's self-injurous behavior.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure an Individual Abuse Prevention Plan (IAPP) was updated after R3's self-injurous behavior. R3 jumped off his family member's second floor balcony during a weekend visit. [...]”

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 ensure history, symptoms, tuberculosis (TB) risk assessment screening were completed and documented for one of two unlicensed personnel (ULP-E) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure history, symptoms, tuberculosis (TB) risk assessment screening were completed and documented for one of two unlicensed personnel (ULP-E) with record reviewed. In addition, ULP-E's employee record did not include her Quantiferon TB test result. [...]”

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 (EP) plan with all the required content.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to have a written emergency preparedness (EP) plan with all the required content. This had the potential to affect 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 accurate resident information and documentation were part of the resident record for two of two current residents (R1, R2), and one former resident (R3) with records reviewed.

MDH’s finding, as written: “Based on interview, and record review, the licensee failed to ensure accurate resident information and documentation were part of the resident record for two of two current residents (R1, R2), and one former resident (R3) with records reviewed. R1 and R2's progress notes record contained multiple random staff conversations, and facility related issues. R1 and R2's record also contained each other's information in their records. In addition, R3's record lacked a discharge summary. [...]”

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 licensee failed to provide smoke alarms immediately outside areas used for sleeping.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide smoke alarms immediately outside areas used for sleeping. 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 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 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.

MDH’s finding, as written: “Based on 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 ensure the assisted living contract did not include language waiving the facility's liability for health, safety, or personal property of a resident.

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. This had the potential to affect the licensee's two current residents (R1, R2). [...]”

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

Summary: MDH found the licensee initiated an expedited termination of the licensee's assisted living contract without having sufficient evidence of reason for one former resident (R3) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee initiated an expedited termination of the licensee's assisted living contract without having sufficient evidence of reason for one former resident (R3) with records reviewed. [...]”

Rule cited: “(a) A facility may initiate an expedited termination of housing or services if: (1) the resident has engaged in conduct that substantially interferes with the rights, health, or safety of other residents; (2) the resident has engaged in conduct that [...]”

Summary: MDH found the licensee failed to provide a written notice of an expedited termination of contract to the Office of Ombudsman for Long Term Care (OOLTC) and failed to give adequate notice of 15 days for one former resident (R3) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a written notice of an expedited termination of contract to the Office of Ombudsman for Long Term Care (OOLTC) and failed to give adequate notice of 15 days for one former resident (R3) with records reviewed. [...]”

Rule cited: “(a) A facility terminating a contract must issue a written notice of termination according to this section. [...]”

Summary: MDH found the licensee failed to ensure competency was completed to include all required content for one of two unlicensed personnel (ULP-A) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure competency was completed to include all required content for one of two unlicensed personnel (ULP-A) with records reviewed. [...]”

Rule cited: “(a) Training and competency evaluations for all unlicensed personnel must include the following: (1) documentation requirements for all services provided; (2) reports of changes in the resident's condition to the supervisor designated by the facility; (3) [...]”

Summary: MDH found the licensee failed to ensure employees received at least eight hours of annul training for each 12 months of employment for one of two unlicensed personnel (ULP)-E with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received at least eight hours of annul training for each 12 months of employment for one of two unlicensed personnel (ULP)-E with record reviewed. [...]”

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 facility licensee failed to provide evidence physical, mental and cognitive needs were assessed with each nursing assessment for two of two residents (R1, R2) reviewed.

MDH’s finding, as written: “Based on interview and record review, the facility licensee failed to provide evidence physical, mental and cognitive needs were assessed with each nursing assessment for two of two residents (R1, R2) reviewed. In addition, the licensee's registered nurse (RN) failed to reassess R1 after he fell three times and was diagnosed with COVID-19. [...]”

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 service plans for two current residents (R1, R2) with records reviewed had signed addendums.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure service plans for two current residents (R1, R2) with records reviewed had signed addendums. The licensee's facility was acquired in a change of ownership (CHOW). R1 and R2 resided in the facility prior to the licensee acquiring the facility in the CHOW. [...]”

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 unlicensed personnel (ULP)-A accurately documented when a medication was administered for one resident (R1) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure unlicensed personnel (ULP)-A accurately documented when a medication was administered for one resident (R1) 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 ensure written or electronically recorded prescriptions were obtained for one of one resident (R1) with record 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 one resident (R1) with record 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 one current resident (R1) Treatment and Therapy Management Plan contained specific instructions for R1's nightly use of a bilevel positive airway pressure (BiPAP) machine with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one current resident (R1) Treatment and Therapy Management Plan contained specific instructions for R1's nightly use of a bilevel positive airway pressure (BiPAP) machine 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 one current resident (R1)'s record contained an up-to-date written or electronically recorded order from an authorized prescriber for all treatments and therapies.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one current resident (R1)'s record contained an up-to-date written or electronically recorded order from an authorized prescriber for all treatments and therapies. R1 required nightly use of a bilevel positive airway pressure (BiPap) machine yet his record lacked evidence of physician orders for his BiPap machine. [...]”

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 they had an awake staff person 24 hours per day seven days per week, who was responsible for responding to the requests of residents for assistance with health and safety needs.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure they had an awake staff person 24 hours per day seven days per week, who was responsible for responding to the requests of residents for assistance with health and safety needs. This affected all two residents. [...]”

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 ensure care and services were provided in accordance with accepted healthcare and medical, or nursing standards for one of one resident (R1) with records reviewed.

MDH’s finding, as written: “Based on interview and document review, the licensee failed to ensure care and services were provided in accordance with accepted healthcare and medical, or nursing standards for one of one resident (R1) with records reviewed. The licensee failed to assess, investigate, or monitor R1 after he fell three times within four hours. The licensee failed to implement individualized interventions to reduce fall risk after R1 fell multiple times. [...]”

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.”