Bridgewater at Mankato

Summary: MDH found the licensee failed to provide a smoke alarm outside within the vicinity of the bedroom of resident apartment unit #12 of building 2 as required by Minnesota Statutes, 144G.45, Subd. 2.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide a smoke alarm outside within the vicinity of the bedroom of resident apartment unit #12 of building 2 as required by Minnesota Statutes, 144G.45, Subd. 2. This has the potential to directly affect resident, 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 portable fire extinguishers in accordance with the State Fire Code as required by MN Statute 144G.45 Subd(a)(2).

MDH’s finding, as written: “Based on observation, record review, and interview, the licensee failed to maintain portable fire extinguishers in accordance with the State Fire Code as required by MN Statute 144G.45 Subd(a)(2). This had the potential to directly affect all residents and staff. [...]”

Rule cited: “(2) install and maintain portable fire extinguishers in accordance with the State Fire Code; (3) install portable fire extinguishers having a minimum 2-A:10-B:C rating within Group R-3 occupancies, as defined by the State Fire Code, located so that the travel [...]”

Summary: MDH found the licensee failed to provide the required documentation on fire protection procedures for residents as part of the fire safety and evacuation plan.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide the required documentation on fire protection procedures for residents as part of the fire safety and evacuation plan. This had the potential to directly affect all residents and staff. [...]”

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 registered nurse (RN) had completed and/or documented a comprehensive assessment for change in condition for three of three residents (R1, R2, R6) related to falls.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the registered nurse (RN) had completed and/or documented a comprehensive assessment for change in condition for three of three residents (R1, R2, R6) related to falls. [...]”

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 service plan was revised, based on resident reassessment for two of three residents (R1, R2) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the service plan was revised, based on resident reassessment for two of three residents (R1, R2) with records reviewed. [...]”

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 the service plan included all required content for three of three residents (R1, R2, R3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the service plan included all required content for three of three residents (R1, R2, R3) with records reviewed. [...]”

Rule cited: “(f) The service plan must include: (1) a description of the services to be provided, the fees for services, and the frequency of each service, according to the resident's current assessment and resident preferences; (2) the identification of staff or [...]”

Summary: MDH found the licensee failed to ensure an individualized medication management plan to include all required content for three of three residents (R1, R2, R3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure an individualized medication management plan to include all required content for three of three residents (R1, R2, R3) with records reviewed. [...]”

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. [...]”

Summary: MDH found the licensee failed to ensure delegated procedures were followed and the registered nurse (RN) specified, in writing, specific instructions for three of three residents (R1, R2, R3) for administration of medications, with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure delegated procedures were followed and the registered nurse (RN) specified, in writing, specific instructions for three of three residents (R1, R2, R3) for administration of medications, with records reviewed. [...]”

Rule cited: “When administration of medications is delegated to unlicensed personnel, the assisted living facility must ensure that the registered nurse has: (1) instructed the unlicensed personnel in the proper methods to administer the medications, and the unlicensed [...]”

Summary: MDH found the licensee failed to ensure medication was administered as prescribed for two of five residents (R1, R5), observed for medication administration and failed to ensure documented site of injection for one of three residents (R1) with records reviewed.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medication was administered as prescribed for two of five residents (R1, R5), observed for medication administration and failed to ensure documented site of injection for one of three residents (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. [...]”

MDH’s finding, as written: “Based on interview and record review the licensee failed to ensure one of three residents (R1) had signed prescriber's orders for medications 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 limited number of residents are [...]”

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 document in the resident's record the disposition of all medications including the medication's name, strength, prescription number as applicable, quantity, to whom the medications were given, date of disposition, and names of staff and other individuals involved in the disposition for one of one discharged resident (R4) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to document in the resident's record the disposition of all medications including the medication's name, strength, prescription number as applicable, quantity, to whom the medications were given, date of disposition, and names of staff and other individuals involved in the disposition for one of one discharged resident (R4) with record reviewed. [...]”

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 ensure an individualized treatments or therapy management plan to include all required content for two of three residents (R1, R3) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure an individualized treatments or therapy management plan to include all required content for two of three residents (R1, R3) 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 an the registered nurse (RN) specified, in writing, specific instructions for each resident and documented those instructions in the resident's records for two of three residents (R1, R3) receiving treatments or therapy and had instructed the unlicensed personnel (ULP) in the proper methods with respect to each resident and the ULP had demonstrated the ability to competently follow the procedures for two of two employees (ULP-F, ULP-G) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure an the registered nurse (RN) specified, in writing, specific instructions for each resident and documented those instructions in the resident's records for two of three residents (R1, R3) receiving treatments or therapy and had instructed the unlicensed personnel (ULP) in the proper methods with respect to each resident and the ULP had demonstrated the ability to competently follow the procedures for two of two [...]”

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 a prescribed treatment was documented accurately for one of

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a prescribed treatment was documented accurately for one of three residents (R1), with records reviewed. [...]”

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

MDH’s finding, as written: “Based on observation, interview and record review the licensee failed to ensure prescriber orders for treatment or therapy for two of three residents (R1, R3) with records reviewed. [...]”

Rule cited: “There must be an up-to-date written or electronically recorded order from an authorized prescriber for all treatments and therapies. [...]”