Brookside Senior Living

Survey completed March 29, 2023: 7 correction orders

• Tag 480: 144G.41 Subd 1 (13) (i) (B) Minimum requirements Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to ensure food was prepared and served according to the Minnesota Food Code.

  MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure food was prepared and served according to the Minnesota Food Code. 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) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large portion or all the [...]”

  Rule cited: “(13) offer to provide or make available at least the following services to residents: (B) food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626; and”

• Tag 650: 144G.42 Subd. 8 Employee records Level 2, isolated scope, scope/level letter D · correction period: Twenty-One (21) days
  Details

  Summary: MDH found the licensee failed to ensure one of two employees' records (clinical nurse supervisor (CNS)-B) included the required content.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one of two employees' records (clinical nurse supervisor (CNS)-B) included the required content. 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: “(a) The facility must maintain current records of each paid employee, each regularly scheduled volunteer providing services, and each individual contractor providing services. [...]”

• Tag 1060: 144G.52 Subd. 9 Emergency relocation Level 2, widespread scope, scope/level letter F · correction period: Twenty-One (21) days
  Details

  Summary: MDH found the licensee failed to provide a written notice with the required content for an emergency relocation and failed to notify the Office of Ombudsman for Long-Term Care of the emergency relocation for one of one resident (R3).

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a written notice with the required content for an emergency relocation and failed to notify the Office of Ombudsman for Long-Term Care of the emergency relocation for one of one resident (R3). This had the potential to affect all residents. [...]”

  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. [...]”

• Tag 1640: 144G.70 Subd. 4 (a-e) Service plan, implementation and revisions to Level 2, isolated scope, scope/level letter D · correction period: Twenty-one
  Details

  Summary: MDH found the licensee failed to ensure the service plan was revised to include all services being provided for two of three residents (R2, R6).

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the service plan was revised to include all services being provided for two of three residents (R2, R6). [...]”

  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. [...]”

• Tag 1760: 144G.71 Subd. 8 Documentation of administration of medication Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure medications were administered as prescribed for one of three residents (R2).

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were administered as prescribed for one of three 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 [...]”

  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. [...]”

• Tag 1890: 144G.71 Subd. 20 Prescription drugs Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure medication was labeled correctly for one of three residents (R1) and failed to ensure medication was not expired for one of three residents (R3).

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medication was labeled correctly for one of three residents (R1) and failed to ensure medication was not expired for one of three residents (R3). [...]”

  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 [...]”

• Tag 1970: 144G.72 Subd. 6 Treatment and therapy orders Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  MDH’s finding, as written: “Based on interview and record review the licensee failed to ensure up-to-date written or electronically recorded orders were maintained for one of one resident (R6) receiving treatments. [...]”

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

From MDH’s letter: no immediate fines.

Allegation, as written: “The resident was sexually abused when an unlicensed staff/alleged perpetrator (AP) was witnessed engage in kissing and close inappropriate intimate contact with a resident.”

“The Minnesota Department of Health determined abuse was inconclusive.”

Summary: MDH looked into an allegation and found: abuse inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined abuse was inconclusive. The AP was observed in the resident's bathroom embracing the resident while kissing him on the lips. The observed contact between the resident and the AP did not rise to the level of abuse. However, it could not be determined if the AP engaged in sexual contact with the resident prior to being observed kissing the resident. Although the resident repeatedly asked for the AP after the incident occurred, the resident has not shown any signs of emotional distress from the incident.”

Action taken by facility: “The facility investigated the incident, and the AP is no longer employed by the facility.”

Action taken by MDH: “The facility was found to be in noncompliance.”

Survey completed August 5, 2024: 1 correction order

• Tag 630: 144G.42 Subd. 6 (b) Compliance with requirements for reporting ma Level 3, isolated scope, scope/level letter G · correction period: Seven (7) Days
  Details

  Summary: MDH found the licensee failed to develop and implement a individual abuse prevention plan (IAPP) with specific interventions for each known vulnerability for one of one resident (R1) reviewed.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop and implement a individual abuse prevention plan (IAPP) with specific interventions for each known vulnerability for one of one resident (R1) reviewed. Although the facility was aware R1 had hypersexual behaviors, R1's assessment did not identify the behavior, and R1's IAPP did not include the behavior or specific interventions for staff on how to respond, manage, or monitor the occurrence of the behavior. [...]”

  Rule cited: “(b) The facility must develop and implement an individual abuse prevention plan for each vulnerable adult. [...]”

Allegation, as written: “The facility neglected the resident when the resident fell, required hospitalization, where a fracture was identified along with severe constipation.”

“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. While the resident did fall in her room, the facility fell and was found on the floor, however the facility sought appropriate care in response to the fall. At the hospital, the resident was found to have severe constipation which was treated there. The resident did have medications prescribed for her on an as-needed basis at the facility, however the facility had not observed any recent symptoms nor had the resident requested these medications.”

Action taken by facility: “The facility followed protocol and sent the resident to the hospital.”

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

Survey completed December 18, 2024: no correction orders issued.