Bethany on the Lake (Assisted Living and Memory Care)

Summary: MDH found the licensee failed to ensure direct supervision of staff performing delegated tasks was provided within 30 calendar days after the date on which the individual begins working for the licensee for one of one unlicensed personnel ((ULP)-D).

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

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 the service plan was revised to reflect the current identification of staff who will provide the services for two of two residents (R3, R4).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the service plan was revised to reflect the current identification of staff who will provide the services for two of two residents (R3, R4). [...]”

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 documentation of medication setup included all the required content for one of one resident (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 one of one resident (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 one of one unlicensed personnel ((ULP)-D) was trained and had demonstrated competency to prepare and give medications for residents having unplanned time away.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure one of one unlicensed personnel ((ULP)-D) was trained and had demonstrated competency to prepare and give medications for residents having unplanned time away. [...]”

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 medications were maintained with legible information including the expiration date for time sensitive medications for one of one resident (R5).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were maintained with legible information including the expiration date for time sensitive medications for one of one resident (R5). In addition, the licensee failed to monitor for expired medications in the licensee's stock 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 prescription drug supply for three of three residents (R2, two unknown residents) were not saved for use by anyone other than the resident for which the medication was prescribed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the prescription drug supply for three of three residents (R2, two unknown residents) were not saved for use by anyone other than the resident for which the medication was prescribed. [...]”

Rule cited: “No prescription drug supply for one resident may be used or saved for use by anyone other than the resident.”

Summary: MDH found the licensee failed to document in the resident's record the disposition of the medications as required for one of one resident (R1) upon discharge.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to document in the resident's record the disposition of the medications as required for one of one resident (R1) upon discharge. [...]”

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. [...]”

Summary: MDH found the licensee failed to provide hazard vulnerability assessment or safety risk assessment of the physical environment with mitigation factors on and around the property for the facility.

MDH’s finding, as written: “Based on record review and interview, the licensee failed to provide hazard vulnerability assessment or safety risk assessment of the physical environment with mitigation factors on and around the property for the facility. This deficient practice had the ability to affect all staff, residents, and visitors. [...]”

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 [...]”