Butterfly Assisted Living

Summary: MDH found the licensee failed to provide a written notice with the required content for an emergency relocation to the resident, legal representative, or designated representative for one of one resident (R4).

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 to the resident, legal representative, or designated representative for one of one resident (R4). [...]”

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 evaluations were completed for all required skill areas, prior to providing services, for two of two employees (unlicensed personnel (ULP)-C and ULP-E).

MDH’s finding, as written: “Based on observation, 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 two of two employees (unlicensed personnel (ULP)-C and ULP-E). [...]”

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 all employees who performed direct services completed all required training components for each twelve months of employment for two of two employees (unlicensed personnel (ULP)-C and ULP-E).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure all employees who performed direct services completed all required training components for each twelve months of employment for two of two employees (unlicensed personnel (ULP)-C and ULP-E). [...]”

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 employees received at least two hours of dementia care training for each 12 months of employment for two of two employees (unlicensed personnel (ULP)-C and ULP-E).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure employees received at least two hours of dementia care training for each 12 months of employment for two of two employees (unlicensed personnel (ULP)-C and ULP-E). [...]”

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 ensure the registered nurse (RN) completed ongoing resident reassessments that did not exceed 90 days for three of three residents (R1, R2, R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) completed ongoing resident reassessments that did not exceed 90 days for three of three residents (R1, R2, R3). [...]”

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 a registered nurse (RN)

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a registered nurse (RN) conducted an assessment to determine what medication management services would be provided, and how the medication services would be provided for one of one resident (R1). [...]”

Rule cited: “(a) For each resident who requests medication management services, the facility shall, prior to providing medication management services, have a registered nurse, licensed health professional, or authorized prescriber under section 151.37 conduct an [...]”

Summary: MDH found the licensee failed to develop and maintain a current individualized medication management record for

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and maintain a current individualized medication management record for each resident to include all required content for three of three residents (R1, R2, and R3). [...]”

Rule cited: “(a) For each resident receiving medication management services, a registered nurse, advanced practice registered nurse, or qualified staff delegated the task by a registered nurse must prepare and include in the service plan a written statement of the [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) specified in writing, specific instructions for medication administration for two of two residents (R1 and R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) specified in writing, specific instructions for medication administration for two of two residents (R1 and R3). [...]”

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 administer medications according to provider orders for one of one resident (R2).

MDH’s finding, as written: “Based on observation and record review, the licensee failed to administer medications according to provider orders for one of one resident (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 limited [...]”

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 prescriptions were renewed at least every 12 months for one of four

MDH’s finding, as written: “Based on observation and record review, the licensee failed to ensure prescriptions were renewed at least every 12 months for one of four 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 [...]”

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 store prescription medication securely and permit only authorized personnel to have access, and the licensee failed to ensure prescription medications were stored according to the manufacturer's directions for one of one resident (R1).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to store prescription medication securely and permit only authorized personnel to have access, and the licensee failed to ensure prescription medications were stored according to the manufacturer's directions for one of one resident (R1). [...]”

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 monitor for expired medications for one of three residents (R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to monitor for expired medications 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 one or a limited [...]”

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 develop and implement a treatment or therapy management plan to include all required content for one of one resident (R1) who had treatments or therapies managed by the licensee.

MDH’s finding, as written: “Based on observation and record review, the licensee failed to develop and implement a treatment or therapy management plan to include all required content for one of one resident (R1) who had treatments or therapies managed by the licensee. [...]”

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 written or electronically recorded orders were obtained for one of one resident (R1) with treatments.

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 (R1) with treatments. [...]”

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

Summary: MDH found the licensee failed to ensure the steps of the medication administration process was followed for one of one employee (unlicensed personnel (ULP)-E) observed administering medications.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the steps of the medication administration process was followed for one of one employee (unlicensed personnel (ULP)-E) observed administering medications. [...]”

Rule cited: “(b) Residents have the right to receive health care and other assisted living services with continuity from people who are properly trained and competent to perform their duties and in sufficient numbers to adequately provide the services agreed to in the [...]”

Summary: MDH found the licensee failed to ensure the required notice was posted at the main entry way of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all current residents in the assisted living facility, staff, and any visitors to the facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure the required notice was posted at the main entry way of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all current residents in the assisted living facility, staff, and any visitors to the facility. [...]”

Rule cited: “(a) A facility must post a sign at each facility entrance accessible to visitors that states: "Electronic monitoring devices, including security cameras and audio devices, may be present to record persons and activities." (b) The facility is responsible for [...]”