Blaine Wp

Summary: MDH found the licensee failed to ensure administration was documented accurately in the medication administration record (MAR) for one of one resident (R4).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure administration was documented accurately in the medication administration record (MAR) for one of one resident (R4). [...]”

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 store all medications in a securely locked location for three of four residents (R2, R3, R4).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to store all medications in a securely locked location for three of four residents (R2, R3, R4). [...]”

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 remove expired medication from availabiltiy for use for three of seven residents (R16, R21, R22).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to remove expired medication from availabiltiy for use for three of seven residents (R16, R21, R22). In addition, the licensee failed to ensure time-sensitive medications were labeled with the date opened for one of seven residents (R21). [...]”

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 identify the prescription number and quantity of all dispositioned medications for one of two discharged residents (R26).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to identify the prescription number and quantity of all dispositioned medications for one of two discharged residents (R26). [...]”

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 administer a prescribed treatment or therapy as ordered and failed to document any follow-up procedures to meet the resident's needs for one of one resident (R4).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to administer a prescribed treatment or therapy as ordered and failed to document any follow-up procedures to meet the resident's needs for one of one resident (R4). [...]”

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

MDH’s finding, as written: “No further action required.”

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 [...]”

Summary: MDH found the licensee failed to report an incident of missing medications to the Minnesota Adult Abuse Reporting Center (MAARC) for one of three discharged residents reviewed (R14).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to report an incident of missing medications to the Minnesota Adult Abuse Reporting Center (MAARC) for one of three discharged residents reviewed (R14). [...]”

Rule cited: “(a) A mandated reporter who has reason to believe that a vulnerable adult is being or has been maltreated, or who has knowledge that a vulnerable adult has sustained a physical injury which is not reasonably explained shall immediately report the information [...]”

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to have a written emergency preparedness plan with all the required content. 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 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 provide a complete fire safety and evacuation plan and the required employee training on the fire safety and evacuation plan.

MDH’s finding, as written: “Based on observation, record review, and interview, the licensee failed to provide a complete fire safety and evacuation plan and the required employee training on the fire safety and evacuation plan. This has the potential to directly affect the safety of all residents receiving services, 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 ensure training and competency evaluations were completed for all required skill areas, prior to providing services, for one of three employees (unlicensed personnel (ULP)-N).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure training and competency evaluations were completed for all required skill areas, prior to providing services, for one of three employees (unlicensed personnel (ULP)-N). [...]”

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 the registered nurse (RN) conducted ongoing resident assessment and reassessment, not to exceed 90 calendar days from the last date of the assessment for one of five residents (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) conducted ongoing resident assessment and reassessment, not to exceed 90 calendar days from the last date of the assessment for one of five residents (R1). [...]”

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 the current service plan included all services to be provided for one of five residents (R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the current service plan included all services to be provided for one of five residents (R2). [...]”

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 store all medications in a securely locked location for one of three residents (R4).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to store all medications in a securely locked location for one of three residents (R4). 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 limited number of residents are affected or [...]”

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.”

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure to discard expired medication for four of four residents (R1, R9, R10, R20). In addition, licensee failed to ensure the overflow medication storage closet had all medications bearing the original prescription label with legible information and did not carry expired medications. This had the potential to affect all residents. [...]”

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 identify the names of staff and other individuals involved in medication disposition per their policy for two of two discharged residents (R6, R14).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to identify the names of staff and other individuals involved in medication disposition per their policy for two of two discharged residents (R6, R14). [...]”

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 develop and implement a treatment or therapy management plan to include all required content for two of five

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop and implement a treatment or therapy management plan to include all required content for two of five residents (R2, R4). [...]”

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 carry out the facility's site-specific safety risk assessment and mitigation plan to protect memory care residents from harm.

MDH’s finding, as written: “Based on observation, document review, and interview, the licensee failed to carry out the facility's site-specific safety risk assessment and mitigation plan to protect memory care residents from harm. This has the potential to directly affect staff and all memory care residents receiving assisted living services. [...]”

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 [...]”

Summary: MDH found the licensee failed to ensure one or more persons were physically present and available 24 hours a day, seven days a week, who were responsible for responding to requests of residents for assistance in the secured unit.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one or more persons were physically present and available 24 hours a day, seven days a week, who were responsible for responding to requests of residents for assistance in the secured unit. This resulted in an immediate correction order issued on June 13, 2023. [...]”

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 [...]”

MDH’s finding, as written: “Surveyor: Anderson, Peggy S. Based on observation, interview, and record review, the licensee failed to maintain a resident's dignity and privacy while performing a 90-day uniform assessment for one of one resident (R7). [...]”

Rule cited: “The licensee of an assisted living facility with dementia care is responsible for the care and housing of the persons with dementia and the provision of person-centered care that promotes each resident's dignity, independence, and comfort. [...]”