Bright Living

MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to establish and maintain an infection control program to comply with acceptable health care, medical nursing standards for infection control after medication administration for one of one (unlicensed personnel (ULP)-C and ensuring the licensee provided adequate supplies to perform proper hand hygiene. [...]”

Rule cited: “(a) All assisted living facilities must establish and maintain an infection control program that complies with accepted health care, medical, and nursing standards for infection control. [...]”

Summary: MDH found the licensee failed to ensure employee records contained the required content for one of two employees (unlicensed personnel (ULP)-E).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure employee records contained the required content for one of two employees (unlicensed personnel (ULP)-E). [...]”

Rule cited: “(a) The facility must maintain current records of each paid employee, each regularly scheduled volunteer providing services, and each individual contractor providing services. [...]”

Summary: MDH found the licensee failed to establish and maintain a tuberculosis (TB) prevention program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included an up-to-date completion of a facility risk assessment.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to establish and maintain a tuberculosis (TB) prevention program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included an up-to-date completion of a facility risk assessment. [...]”

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 and post a written emergency preparedness plan (EPP) with all the required content.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and post a written emergency preparedness plan (EPP) with all the required content. This had the potential to affect all residents, staff, and visitors of 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 maintain resident records with current, legible, permanently recorded, dated, and authenticated with the name and title of the person making the entry for one of one resident (R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to maintain resident records with current, legible, permanently recorded, dated, and authenticated with the name and title of the person making the entry for one of one resident (R3). [...]”

Rule cited: “(a) Assisted living facilities must maintain records for each resident for whom it is providing services. [...]”

Summary: MDH found the licensee failed to ensure that the appropriate records for two of two residents (R2, R3), were readily available for timely access to employees, vendors, and the commissioner authorized to access the records.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure that the appropriate records for two of two residents (R2, R3), were readily available for timely access to employees, vendors, and the commissioner authorized to access the records. [...]”

Rule cited: “The facility must ensure that the appropriate records are readily available to employees and contractors authorized to access the records. Resident records must be maintained in a manner that allows for timely access, printing, or transmission of the records. [...]”

Summary: MDH found the licensee failed to provide interconnected smoke alarms throughout the facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide interconnected smoke alarms throughout the facility. This had the potential to directly affect all residents, 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 the facility's physical environment in a continuous state of good repair

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

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 required content, make the plan readily available, provide required training and 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 required content, make the plan readily available, provide required training and 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 ensure the assisted living contract did not include language waiving

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the assisted living contract did not include language waiving the facility's liability for health, safety, or personal property of a resident for two of two residents (R2, R3). [...]”

Rule cited: “The contract must not include a waiver of facility liability for the health and safety or personal property of a resident. [...]”

Summary: MDH found the licensee failed to ensure all employees with access to residents and resident records had a cleared background study completed via Minnesota Department of Human Services (DHS)NetStudy 2.0, for one of six employees (unlicensed personnel (ULP)-D).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure all employees with access to residents and resident records had a cleared background study completed via Minnesota Department of Human Services (DHS)NetStudy 2.0, for one of six employees (unlicensed personnel (ULP)-D). This had the potential to affect all residents, employees, and visitors. [...]”

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 training and competency evaluations included all the required training for one of two employees (unlicensed personnel (ULP)-C).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure training and competency evaluations included all the required training for one of two employees (unlicensed personnel (ULP)-C). [...]”

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 training and competency evaluations included all the required training for one of two employees (unlicensed personnel (ULP)-C).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure training and competency evaluations included all the required training for one of two employees (unlicensed personnel (ULP)-C). [...]”

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 staff providing and supervising direct services completed orientation to assisted living facility licensing requirements and regulations before providing services for one of two employees (clinical nurse supervisor (CNS)-B).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure staff providing and supervising direct services completed orientation to assisted living facility licensing requirements and regulations before providing services for one of two employees (clinical nurse supervisor (CNS)-B). This had the potential to affect all residents. [...]”

Rule cited: “All staff providing and supervising direct services must complete an orientation to assisted living facility licensing requirements and regulations before providing assisted living services to residents. [...]”

Summary: MDH found the licensee failed to ensure staff providing services completed an orientation to assisted living facility licensing requirements and regulations before providing services for two of two employees (unlicensed personnel (ULP)-C, ULP-E).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure staff providing services completed an orientation to assisted living facility licensing requirements and regulations before providing services for two of two employees (unlicensed personnel (ULP)-C, ULP-E). [...]”

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 the required amount of dementia care training was completed in the required time frame in accordance with 144G.64 for three of three employees (clinical nurse supervisor (CNS)-B, unlicensed personnel (ULP)-C, ULP-E).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the required amount of dementia care training was completed in the required time frame in accordance with 144G.64 for three of three employees (clinical nurse supervisor (CNS)-B, unlicensed personnel (ULP)-C, ULP-E). [...]”

Rule cited: “All direct care staff and supervisors providing direct services must demonstrate an understanding of the training specified in section 144G.64.”

Summary: MDH found the licensee failed to ensure three of three employees (clinical nurse supervisor (CNS)-B, unlicensed personnel (ULP)-C, ULP-E) received the required amount of dementia care training in the required time frame.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure three of three employees (clinical nurse supervisor (CNS)-B, unlicensed personnel (ULP)-C, ULP-E) received the required amount of dementia care training in the required time frame. [...]”

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 the service plan was revised to reflect the current services provided for one of two residents (R2).

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 services provided for one of two 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 ensure the registered nurse (RN) instructed unlicensed personnel (ULP)-C, ULP-D) in the proper methods to administer medications, and the unlicensed personnel had demonstrated the ability to competently follow the procedures for administering medications.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the registered nurse (RN) instructed unlicensed personnel (ULP)-C, ULP-D) in the proper methods to administer medications, and the unlicensed personnel had demonstrated the ability to competently follow the procedures for administering medications. This had the potential to affect all residents receiving assisted living services. [...]”

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 medications were administered per the manufacturer's instructions for one of two residents (R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were administered per the manufacturer's instructions for one of two residents (R2). [...]”

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 ensure two of unlicensed personnel (ULP-C, ULP-E) were 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 two of unlicensed personnel (ULP-C, ULP-E) were trained and had demonstrated competency to prepare and give medications for residents having unplanned time away. In addition, the licensee failed to ensure the registered nurse (RN) developed written procedures with all the required content for ULP providing medications for residents having unplanned time away when the licensed nurse was not available. [...]”

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 current written or electronically recorded prescriptions were obtained for one of two residents (R3) who received medication management services.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure current written or electronically recorded prescriptions were obtained for one of two residents (R3) who received medication management services. [...]”

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 renew prescriptions at least every 12 months for one of two residents (R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to renew prescriptions at least every 12 months for one of two residents (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 an isolated scope (when one or a limited number of residents are affected or one or a [...]”

Rule cited: “Prescriptions must be renewed at least every 12 months or more frequently as indicated by the assessment in subdivision 2. Prescriptions for controlled substances must comply with chapter 152.”

Summary: MDH found the licensee failed to ensure refrigerated medications were maintained at manufacturer recommended temperatures by failing to monitor and document medication refrigerator temperatures for one of one medication refrigerator.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure refrigerated medications were maintained at manufacturer recommended temperatures by failing to monitor and document medication refrigerator temperatures for one of one medication refrigerator. [...]”

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 medications were maintained bearing the original prescription label with information regarding the direction for use, medication name, medication dosage, resident's name, and the pharmacy in which it had been issued for one of two residents (R2) who received medication storage by the licensee.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were maintained bearing the original prescription label with information regarding the direction for use, medication name, medication dosage, resident's name, and the pharmacy in which it had been issued for one of two residents (R2) who received medication storage by the licensee. [...]”

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 document in the resident 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 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 ensure instructions, specified in writing for each resident, and documented those instructions in the resident's record for one of one resident (R2) who received blood glucose monitoring.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure instructions, specified in writing for each resident, and documented those instructions in the resident's record for one of one resident (R2) who received blood glucose monitoring. [...]”

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 written or electronically recorded orders were obtained for one of one resident (R2) who had treatments managed by the provider.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure written or electronically recorded orders were obtained for one of one resident (R2) who had treatments managed by the provider. [...]”

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