Brooke Manor

Summary: MDH found the licensee failed to ensure employee records contained required content for three of three employees (unlicensed personnel (ULP)-F, ULP-H, clinical nurse supervisor (CNS) -C).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure employee records contained required content for three of three employees (unlicensed personnel (ULP)-F, ULP-H, clinical nurse supervisor (CNS) -C). [...]”

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

Summary: MDH found the licensee failed to have a written emergency preparedness plan (EPP) with all the required content and failed to post an emergency preparedness plan prominently.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to have a written emergency preparedness plan (EPP) with all the required content and failed to post an emergency preparedness plan prominently. 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 comply with the requirements of Minnesota State Fire Code Rules, Chapter 7511.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to comply with the requirements of Minnesota State Fire Code Rules, Chapter 7511. 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 pattern scope (when more than a limited number of residents are affected, more than a limited [...]”

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 an interconnected smoke alarm in a resident sleeping room that complied with fire protection requirements.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide an interconnected smoke alarm in a resident sleeping room that complied with fire protection requirements. [...]”

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 install and maintain the portable fire extinguishers as required by statute.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to install and maintain the portable fire extinguishers as required by statute. 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 pattern scope (when more than a limited number of residents are affected, more than a limited number [...]”

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 [...]”

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide the physical environment in a continuous state of good repair and operation with regard to the health, safety, and well-being of the residents. [...]”

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, and provide required training and drills.

MDH’s finding, as written: “Based on record review and interview, the licensee failed to develop the fire safety and evacuation plan with required content, and 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 two of two resident's (R7, R8) assisted living contract included a notice with the required verbiage for the residents to identify a designated representative.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure two of two resident's (R7, R8) assisted living contract included a notice with the required verbiage for the residents to identify a designated representative. This had the potential to affect all residents who received services at the facility. [...]”

Rule cited: “(a) Before or at the time of execution of an assisted living contract, an assisted living facility must offer the resident the opportunity to identify a designated representative in writing in the contract and must provide the following verbatim notice on a [...]”

Summary: MDH found the licensee failed to provide a written notice with required content to the resident, legal representative, and designated representative; and failed to provide the notification to the Office of Ombudsman for Long-Term Care (OOLTC) when the resident did not return from the emergency relocation within four days for one of one resident (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a written notice with required content to the resident, legal representative, and designated representative; and failed to provide the notification to the Office of Ombudsman for Long-Term Care (OOLTC) when the resident did not return from the emergency relocation within four days for one of one resident (R1). [...]”

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 training and competency demonstration by the registered nurse (RN) was completed for three of three unlicensed personnel (ULP-F, ULP-H, ULP-G).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure training and competency demonstration by the registered nurse (RN) was completed for three of three unlicensed personnel (ULP-F, ULP-H, ULP-G). Additionally, the licensee failed to provide written instructions in one of one resident record (R2) for delegated tasks to include personal alarms. [...]”

Rule cited: “(b) When the registered nurse or licensed health professional delegates tasks to unlicensed personnel, that person must ensure that prior to the delegation the unlicensed personnel is trained in the proper methods to perform the tasks or procedures for each [...]”

Summary: MDH found the licensee failed to ensure one of two employees (clinical nurse supervisor (CNS) -C), received the required amount of dementia, mental illness, and

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one of two employees (clinical nurse supervisor (CNS) -C), received the required amount of dementia, mental illness, and de-escalation training required. [...]”

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 employees received all required content of annual training for each 12 months of employment for two of two employees (clinical nurse supervisor (CNS) -C, unlicensed personnel (ULP)-F).

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

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 one of two employees (clinical nurse supervisor (CNS) -C), received the required amount of annual dementia care training and training on topics required in the time frame required.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one of two employees (clinical nurse supervisor (CNS) -C), received the required amount of annual dementia care training and training on topics required in the time frame required. [...]”

Rule cited: “(a) All assisted living facilities must meet the following dementia care, mental illness, and de-escalation training requirements: (1) supervisors of direct-care staff must have at least eight hours of initial training on dementia topics specified under [...]”

Summary: MDH found the licensee failed to provide to consumers in written or electronic form a description of the training program, the categories of employees trained, the frequency of training, and the basic topics covered to include mental illness and de-escalation as required.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide to consumers in written or electronic form a description of the training program, the categories of employees trained, the frequency of training, and the basic topics covered to include mental illness and de-escalation as required. [...]”

Rule cited: “(a) The facility shall provide to consumers in written or electronic form a description of the training program, the categories of staff trained, the frequency of training, and the basic topics covered.”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) completed ongoing resident reassessments that did not exceed 14 days for one of one resident (R7) and did not exceed 90 days for one of one resident (R6).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the registered nurse (RN) completed ongoing resident reassessments that did not exceed 14 days for one of one resident (R7) and did not exceed 90 days for one of one resident (R6). In addition, the licensee failed to ensure the RN completed an alarm assessment for one of one resident, (R2). [...]”

Rule cited: “(a) Residents who are not receiving any assisted living services shall not be required to undergo an initial nursing assessment. [...]”

Summary: MDH found the licensee failed to ensure service plans were authenticated to confirm agreement of the services to be provided for two of two residents (R7, R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure service plans were authenticated to confirm agreement of the services to be provided for two of two residents (R7, R2). In addition, the licensee failed to ensure service plans were revised to include provided services for two of two residents (R8, 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) in the proper methods to administer medications, and ULP had demonstrated the ability to competently follow the procedures for administering medications, for three of three ULP (ULP-F, ULP-H, ULP-G).

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) in the proper methods to administer medications, and ULP had demonstrated the ability to competently follow the procedures for administering medications, for three of three ULP (ULP-F, ULP-H, ULP-G). 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 one of one unlicensed personnel (ULP-G) and all other ULPs were trained and had demonstrated competency for the procedure of medications for residents having unplanned time away.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one of one unlicensed personnel (ULP-G) and all other ULPs were trained and had demonstrated competency for the procedure of medications for residents having unplanned time away. Further, the licensee failed to ensure the registered nurse (RN) developed a comprehensive written procedure for the unlicensed personnel (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 medications were secure and permitted access to only authorized personnel for one of three residents (R7).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were secure and permitted access to only authorized personnel for one of three residents (R7). [...]”

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 legible information, including the expiration date, for time sensitive medications for five of five residents (R7, R3, R6, R5, R2).

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 legible information, including the expiration date, for time sensitive medications for five of five residents (R7, R3, R6, R5, R2). In addition, the licensee failed to monitor for expired medication for one of five residents (R6). [...]”

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 ensure prior to delegating nursing tasks, the registered nurse (RN) trained unlicensed personnel (ULP) and had ULP demonstrate the ability to follow the procedure for three of three employees (ULP-F, ULP-H, ULP-G).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure prior to delegating nursing tasks, the registered nurse (RN) trained unlicensed personnel (ULP) and had ULP demonstrate the ability to follow the procedure for three of three employees (ULP-F, ULP-H, ULP-G). Additionally, the licensee failed to ensure the RN prepared in writing specific instructions for each resident and documented those instructions for one of one resident (R8) receiving treatments. [...]”

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 the care and services were provided according to acceptable health care and medical, or nursing standards for one of three residents (R8) with hospital-style bed rails.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the care and services were provided according to acceptable health care and medical, or nursing standards for one of three residents (R8) with hospital-style bed rails. Further, the licensee failed to provide care and services according to acceptable health care, medical, or nursing standards for storage of oxygen for one of two residents (R3) with an oxygen tank. [...]”

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.”

Summary: MDH found the licensee failed to ensure resident's personal health and medical information was kept private.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure resident's personal health and medical information was kept private. This had the potential to affect all residents residing at the assisted living facility. [...]”

Rule cited: “(a) Residents have the right to have personal, financial, health, and medical information kept private, to approve or refuse release of information to any outside party, and to be advised of the assisted living facility's policies and procedures regarding [...]”