Bethel Haven Care

Summary: MDH found the licensee failed to maintain a tuberculosis (TB) prevention and control program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to maintain a tuberculosis (TB) prevention and control program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC). The licensee failed to ensure screening for active TB (either a two-step tuberculin skin test (TST) or blood test) were completed and documented for two of four employees, (unlicensed personnel (ULP)-H and ULP-J). [...]”

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 develop a written emergency preparedness (EP) plan with all the required content.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop a written emergency preparedness (EP) plan with all the required content. This had the potential to affect all residents, employees, and visitors to the facility. [...]”

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 provide facilities that were not a distinct hazard to life.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide facilities that were not a distinct hazard to life. This had the potential to directly affect all of the residents and staff. [...]”

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 smoke alarms that are interconnected so that actuation of one alarm causes all alarms in the facility to actuate.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide smoke alarms that are interconnected so that actuation of one alarm causes all alarms in the facility to actuate. This deficient condition had the ability to affect all staff and residents. [...]”

Rule cited: “for dwellings or sleeping units, as defined in the State Fire Code: (i) provide smoke alarms in each room used for sleeping purposes; (ii) provide smoke alarms outside each separate sleeping area in the immediate vicinity of bedrooms; (iii) provide smoke [...]”

Summary: MDH found the licensee failed to maintain the physical environment of the facility in a continuous state of good repair and operation.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the physical environment of the facility in a continuous state of good repair and operation. This has the potential to directly affect the health, safety, and well-being of all residents, visitors, and staff. [...]”

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 the fire safety and evacuation plan with the required content, the licensee failed to document required fire safety evacuation training for employees and residents and complete the required annual fire drills.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop the fire safety and evacuation plan with the required content, the licensee failed to document required fire safety evacuation training for employees and residents and complete the required annual fire drills. This had the potential to directly affect all residents, staff, and visitors. [...]”

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 for one of one resident (R3).

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 for one of one resident (R3). 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) 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 current employee records contained a background study clearance letter for one of 11 employees (unlicensed personnel (ULP)-G).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure current employee records contained a background study clearance letter for one of 11 employees (unlicensed personnel (ULP)-G). In addition, the licensee failed to affiliate employee background studies with the correct healthcare facility identification (HFID) for three of 11 employees (unlicensed personnel/housing manager (ULP/HM-F), director of maintenance DM-D, and ULP-I). [...]”

Rule cited: “(a) Employees, contractors, and regularly scheduled volunteers of the facility are subject to the background study required by section 144.057 and may be disqualified under chapter 245C. [...]”

Summary: MDH found the licensee failed to ensure required training was completed for two of two employees (unlicensed personnel (ULP)-H and ULP-J).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure required training was completed for two of two employees (unlicensed personnel (ULP)-H and ULP-J). [...]”

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 required training was completed for two of two employees (unlicensed personnel (ULP)-H and ULP-J).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure required training was completed for two of two employees (unlicensed personnel (ULP)-H and ULP-J). [...]”

Rule cited: “(b) In addition to paragraph (a), training and competency evaluation for unlicensed personnel providing assisted living services must include: (1) observing, reporting, and documenting resident status; (2) basic knowledge of body functioning and changes in [...]”

Summary: MDH found the licensee failed to ensure employees received orientation to assisted living facility licensing requirements and regulations prior to providing services for four of four employees (unlicensed personnel/housing manager (ULP/HM)-F, unlicensed personnel (ULP)-E, ULP-H, and ULP-J).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure employees received orientation to assisted living facility licensing requirements and regulations prior to providing services for four of four employees (unlicensed personnel/housing manager (ULP/HM)-F, unlicensed personnel (ULP)-E, ULP-H, and ULP-J). [...]”

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 two of two employees (clinical nurse supervisor (CNS)-B and unlicensed personnel (ULP)-H.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure annual training included all required topics for each 12 months of employment for two of two employees (clinical nurse supervisor (CNS)-B and unlicensed personnel (ULP)-H. [...]”

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 all employees received eight (8) hours of initial dementia care training within the first 160 working hours of employment for two of two employees, (unlicensed personnel/housing manager (ULP/HM)-F and unlicensed personnel (ULP)-J); and two (2) hours of annual dementia care training for direct care employees as required for two of two employees, (clinical nurse supervisor

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure all employees received eight (8) hours of initial dementia care training within the first 160 working hours of employment for two of two employees, (unlicensed personnel/housing manager (ULP/HM)-F and unlicensed personnel (ULP)-J); and two (2) hours of annual dementia care training for direct care employees as required for two of two employees, (clinical nurse supervisor (CNS)-B and unlicensed personnel (ULP)-H). [...]”

Rule cited: “(a) All assisted living facilities must meet the following training requirements: (1) supervisors of direct-care staff must have at least eight hours of initial training on topics specified under paragraph (b) within 120 working hours of the employment start [...]”

Summary: MDH found the licensee failed to ensure a registered nurse (RN) conducted ongoing assessments not to exceed 90 calendar days from the last date of assessment for three of three residents (R2, R3, and R5).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure a registered nurse (RN) conducted ongoing assessments not to exceed 90 calendar days from the last date of assessment for three of three residents (R2, R3, and R5). [...]”

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 complete a service plan within 14 days of admission for three of three residents (R2, R3, and R5).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to complete a service plan within 14 days of admission for three of three residents (R2, R3, and R5). [...]”

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 an individual medication management plan to include all required content for three of three residents (R2, R3, and R4).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop an individual medication management plan to include all required content for three of three residents (R2, R3, and R4). [...]”

Rule cited: “(a) For each resident receiving medication management services, the assisted living facility must prepare and include in the service plan a written statement of the medication management services that will be provided to the resident. [...]”

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 one of one employee (unlicensed personnel/housing manager (ULP/HM)-F). [...]”

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 [...]”

MDH’s finding, as written: “Based on observation, interview, record review the licensee failed to properly store and secure medications, as required for one of one resident (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, but was not likely to cause serious injury, impairment, or death) and was issued at a isolated scope (when one or a limited number of residents are affected or one or a [...]”

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.”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) developed and maintained a current individualized treatment and therapy record for two of two residents (R2 and R3) who had ordered treatments.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the registered nurse (RN) developed and maintained a current individualized treatment and therapy record for two of two residents (R2 and R3) who had ordered treatments. [...]”

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 prior to delegating nursing tasks of treatment administration, the unlicensed personnel (ULP) were trained in the proper methods to perform treatments and the ULP demonstrated competency back to the registered nurse (RN) for three of three employees (unlicensed personnel/housing manager (ULP/HM)-F, and unlicensed personnel (ULP)-H and ULP-J).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure prior to delegating nursing tasks of treatment administration, the unlicensed personnel (ULP) were trained in the proper methods to perform treatments and the ULP demonstrated competency back to the registered nurse (RN) for three of three employees (unlicensed personnel/housing manager (ULP/HM)-F, and unlicensed personnel (ULP)-H and ULP-J). [...]”

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 documentation of administration of or the reason why a treatment was not administered and any follow-up procedures that were provided for one of two residents (R2) receiving treatments.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure documentation of administration of or the reason why a treatment was not administered and any follow-up procedures that were provided for one of two residents (R2) receiving treatments. [...]”

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

Summary: MDH found the licensee failed to ensure up-to-date written or electronically recorded orders were maintained for the licensee's two residents (R2 and R3) receiving treatments.

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 the licensee's two residents (R2 and R3) 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 provide care and services according to acceptable health care, medical, or nursing standards related to secure oxygen tank storage for one of one resident (R4).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to provide care and services according to acceptable health care, medical, or nursing standards related to secure oxygen tank storage for one of one resident (R4). [...]”

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.”