Cedar Heart Homes

Summary: MDH found the licensee failed to comply with the current Minnesota Fire Code Provisions.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to comply with the current Minnesota Fire Code Provisions. This had the potential to directly affect all residents, staff, and visitors. [...]”

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 develop the fire safety and evacuation plan with required content, failed to provide the required training, and failed to conduct evacuation drills.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop the fire safety and evacuation plan with required content, failed to provide the required training, and failed to conduct evacuation 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 one of one staff (unlicensed personnel (ULP)-F) completed all required topics in orientation to assisted living facility licensing requirements and regulations, before providing services.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure one of one staff (unlicensed personnel (ULP)-F) completed all required topics in orientation to assisted living facility licensing requirements and regulations, before providing services. [...]”

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 registered nurse (RN) completed a timely comprehensive assessment for a change in condition for one of one resident (R3)

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) completed a timely comprehensive assessment for a change in condition for one of one resident (R3) 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 [...]”

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 the current service plan included a signature or other authentication by the resident to document agreement on the services to be provided for two of two residents (R2, R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the current service plan included a signature or other authentication by the resident to document agreement on the services to be provided for two of two residents (R2, R3). [...]”

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 administer medications according to prescriber orders for two of two residents (R2, R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to administer medications according to prescriber orders for two of two residents (R2, R3). 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 [...]”

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 the registered nurse (RN) trained and ensured competency for two of two employees (unlicensed personnel (ULP)-D, ULP-F) providing medications for residents with unplanned time away from home when the licensed nurse was not available.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) trained and ensured competency for two of two employees (unlicensed personnel (ULP)-D, ULP-F) providing medications for residents with unplanned time away from home 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 include the date

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to include the date opened of a time-sensitive drug for one of one resident (R2) and medications were not expired for the licensee's house medication supply. This had the potential to affect all residents. [...]”

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 a treatment management plan to include all required content for one of two residents (R2) who received treatments.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop a treatment management plan to include all required content for one of two residents (R2) who received treatments. [...]”

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 documentation that treatments were completed

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure documentation that treatments were completed as instructed for one of two residents (R2) who had an ordered treatment. [...]”

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

Summary: MDH found the licensee failed to ensure the required notice was posted at the main entrance 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 of the licensee.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the required notice was posted at the main entrance 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 of the licensee. [...]”

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 [...]”