Birchwood Cottages

Survey completed September 21, 2022: 7 correction orders

• Tag 470: 144G.41 Subdivision 1 Minimum requirements Level 1, widespread scope, scope/level letter C · correction period: Twenty-one (21) days
  Details

  MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to ensure the staff posting included all the required elements, potentially affecting all the licensee's current residents, staff, and visitors. [...]”

  Rule cited: “(11) develop and implement a staffing plan for determining its staffing level that: (i) includes an evaluation, to be conducted at least twice a year, of the appropriateness of staffing levels in the facility; (ii) ensures sufficient staffing at all times to [...]”

• Tag 780: 144G.45 Subd. 2 (a) (1) Fire protection and physical environment Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
  Details

  MDH’s finding, as written: “Based on observation and interview, the licensee failed provide smoke alarms in each sleeping room throughout the facility. This deficient condition had the ability to affect all staff and residents. [...]”

  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) [...]”

• Tag 810: 144G.45 Subd. 2 (b)-(f) Fire protection and physical environment Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to provide required employee training on fire safety and evacuation and failed to conduct the required evacuation drills.

  MDH’s finding, as written: “Based on a record review and interview, the licensee failed to provide required employee training on fire safety and evacuation and failed to conduct the required evacuation drills. This had the potential to affect all staff, residents, and visitors. [...]”

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

• Tag 1440: 144G.62 Subd. 4 Supervision of staff providing delegated nurs Level 2, isolated scope, scope/level letter D · correction period: Twenty-One
  Details

  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-E).

  MDH’s finding, as written: “Based on 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-E). [...]”

  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 [...]”

• Tag 1770: 144G.71 Subd. 9 Documentation of medication setup Level 2, isolated scope, scope/level letter D
  Details

  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 two residents (R1) with records reviewed 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 an isolated scope (when one or a [...]”

  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.”

• Tag 1790: 144G.71 Subd. 10 Medication management for residents who will Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure the registered nurse (RN) developed training and competencies for the unlicensed personnel (ULP) providing medications for residents with unplanned time away from home when the licensed nurse was

  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 the unlicensed personnel (ULP) providing medications for residents with unplanned time away from home when the licensed nurse was not available for one of one unlicensed personnel (ULP-D). [...]”

  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 [...]”

• Tag 2110: 144G.82 Subd. 3 Policies Level 2, widespread scope, scope/level letter F · correction period: Twenty-one
  Details

  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/or the resident's legal and designated representative at the time of move-in for three of three residents (R1, R2, R3).

  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/or the resident's legal and designated representative at the time of move-in for three of three residents (R1, R2, R3). [...]”

  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 [...]”

From MDH’s letter: no immediate fines.

Allegation, as written: “The facility neglected the resident when the facility failed to implement intervention(s) to prevent the resident from injury following a number of falls. The resident fell, obtained a fractured skull, and fractured cervical spine. The resident was taken to the emergency room.”

“The Minnesota Department of Health determined neglect was not substantiated.”

Summary: MDH looked into an allegation and found: neglect not substantiated.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was not substantiated. Facility staff members provided care according to the resident's plan of care. While the resident did fall and sustain injuries, the facility assessed for falls, and put appropriate interventions and services in place.”

Action taken by facility: “The facility investigated the incident and sent the resident to the hospital.”

Action taken by MDH: “No further action taken at this time.”

Survey completed July 16, 2024: no correction orders issued.